Quantitative Kinetoplast DNA Assessment During Treatment of Mucosal Leishmaniasis as a Potential Biomarker of Outcome: A Pilot Study

Marlene Jara Instituto de Medicina Tropical “Alexander von Humboldt,” Universidad Peruana Cayetano Heredia, Lima, Peru; Public Health Ontario Laboratories, Public Health Ontario, Toronto, Canada; Department of Medicine, University of Toronto, Canada; Tropical Disease Unit, University Health Network Toronto General Hospital, Toronto, Canada

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Braulio Mark Valencia Instituto de Medicina Tropical “Alexander von Humboldt,” Universidad Peruana Cayetano Heredia, Lima, Peru; Public Health Ontario Laboratories, Public Health Ontario, Toronto, Canada; Department of Medicine, University of Toronto, Canada; Tropical Disease Unit, University Health Network Toronto General Hospital, Toronto, Canada

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Vanessa Adaui Instituto de Medicina Tropical “Alexander von Humboldt,” Universidad Peruana Cayetano Heredia, Lima, Peru; Public Health Ontario Laboratories, Public Health Ontario, Toronto, Canada; Department of Medicine, University of Toronto, Canada; Tropical Disease Unit, University Health Network Toronto General Hospital, Toronto, Canada

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Milena Alba Instituto de Medicina Tropical “Alexander von Humboldt,” Universidad Peruana Cayetano Heredia, Lima, Peru; Public Health Ontario Laboratories, Public Health Ontario, Toronto, Canada; Department of Medicine, University of Toronto, Canada; Tropical Disease Unit, University Health Network Toronto General Hospital, Toronto, Canada

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Rachel Lau Instituto de Medicina Tropical “Alexander von Humboldt,” Universidad Peruana Cayetano Heredia, Lima, Peru; Public Health Ontario Laboratories, Public Health Ontario, Toronto, Canada; Department of Medicine, University of Toronto, Canada; Tropical Disease Unit, University Health Network Toronto General Hospital, Toronto, Canada

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Jorge Arevalo Instituto de Medicina Tropical “Alexander von Humboldt,” Universidad Peruana Cayetano Heredia, Lima, Peru; Public Health Ontario Laboratories, Public Health Ontario, Toronto, Canada; Department of Medicine, University of Toronto, Canada; Tropical Disease Unit, University Health Network Toronto General Hospital, Toronto, Canada

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Alejandro Llanos-Cuentas Instituto de Medicina Tropical “Alexander von Humboldt,” Universidad Peruana Cayetano Heredia, Lima, Peru; Public Health Ontario Laboratories, Public Health Ontario, Toronto, Canada; Department of Medicine, University of Toronto, Canada; Tropical Disease Unit, University Health Network Toronto General Hospital, Toronto, Canada

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Andrea K. Boggild Instituto de Medicina Tropical “Alexander von Humboldt,” Universidad Peruana Cayetano Heredia, Lima, Peru; Public Health Ontario Laboratories, Public Health Ontario, Toronto, Canada; Department of Medicine, University of Toronto, Canada; Tropical Disease Unit, University Health Network Toronto General Hospital, Toronto, Canada

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Mucosal leishmaniasis (ML) is a disfiguring manifestation of Leishmania (Viannia) infection. We evaluated parasite load (PL) over time as a potential biomarker of treatment outcome in ML. PL was assessed with kinetoplast DNA quantitative real-time polymerase chain reaction (kDNA-qPCR) at enrollment, days 14 and 21–28 of therapy and 3, 6, 12–18, and 18–24 months after treatment of ML and correlated to demographic, clinical, and parasitologic factors. Forty-four patients were enrolled: 30 men and 14 women. Enrollment PL differed significantly by causative species (P < 0.001), and was higher in patients with severe ML (nasal and laryngeal involvement) compared with those with only isolated nasal involvement (median = 1,285 versus 51.5 parasites/μg tissue DNA; P = 0.005). Two patterns of PL emerged: pattern 1 (N = 23) was characterized by a sequential decline in PL during and after therapy until kDNA was undetectable. Pattern 2 (N = 18) was characterized by clearance of detectable kDNA during treatment, followed by an increased PL thereafter. All patients who failed treatment (N = 4) demonstrated pattern 1. Leishmania (Viannia) braziliensis was overrepresented among those with pattern 2 (P = 0.019). PL can be quantified by cytology brush qPCR during and after treatment in ML. We demonstrate that treatment failure was associated with undetectable PL, and L. (V.) braziliensis infection was overrepresented in those with rebounding PL.

Author Notes

* Address correspondence to Andrea K. Boggild, Tropical Disease Unit, Toronto General Hospital, 200 Elizabeth Street, 13EN-218, Toronto, ON M5G 2C4, Canada. E-mail: andrea.boggild@utoronto.ca
† These authors contributed equally to this work.

Financial support: This study was funded by the American Society of Tropical Medicine and Hygiene through the Gorgas Memorial Institute Research Award (Andrea K. Boggild). Personnel and facility support for the Arevalo molecular laboratory (Marlene Jara, Milena Alba, Vanessa Adaui, and Jorge Arevalo) was provided by the Institutional Collaboration Framework Agreement 3 from the Belgian Directorate-General for Development (project 95502). Marlene Jara was a Fogarty Scholar supported by NIH/Fogarty International Center Global Infectious Diseases Training Grant D43TW007120 during the study period.

Authors' addresses: Marlene Jara, Vanessa Adaui, Milena Alba, and Jorge Arevalo, Departmento de Bioquimica, Biologia Molecular y Farmacologia, Facultad de Ciencias, Universidad Peruana Cayetano Heredia, Lima, Peru, E-mails: jara_marlene@yahoo.es, vanessa.adaui@upch.pe, milenacollado@yahoo.es, and biomoljazz@gmail.com. Braulio Mark Valencia and Alejandro Llanos-Cuentas, Institute of Tropical Medicine Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima , Peru, E-mails: braulio.valencia@upch.pe and alejandro.llanos.c@upch.pe. Rachel Lau, Public Health Ontario Laboratories, Toronto, Canada, E-mail: rachel.lau@oahpp.ca. Andrea K. Boggild, Tropical Disease Unit, Toronto General Hospital, Toronto, Canada, E-mail: andrea.boggild@utoronto.ca.

  • 1.

    David CV, Craft N, 2009. Cutaneous and mucocutaneous leishmaniasis. Derm Ther 22: 491502.

  • 2.

    Lucas CM, Franke ED, Cachay MI, Tejada A, Cruz ME, Kreutzer RD, Barker DC, McCann SH, Watts DM, 1998. Geographic distribution and clinical description of leishmaniasis cases in Peru. Am J Trop Med Hyg 59: 312317.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Valencia BM, Veland N, Adaui V, Arevalo J, Low DE, Llanos-Cuentas A, Boggild AK, 2012. Non-invasive cytology brush PCR diagnostic testing in mucosal leishmaniasis: superior performance to conventional biopsy with histopathology. PLoS One 6: e26395.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Mary C, Faraut F, Drogoul MP, Xeridat B, Schleinitz N, Cuisenier B, Dumon H, 2006. Reference values for Leishmania infantum parasitemia in different clinical presentations: quantitative polymerase chain reaction for therapeutic monitoring and patient follow-up. Am J Trop Med Hyg 75: 858863.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    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.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Dorlo TP, van Thiel PP, Schoone GJ, Stienstra Y, van Vugt M, Beijnen JH, de Vries PJ, 2011. Dynamics of parasite clearance in cutaneous leishmaniasis patients treated with miltefosine. PLoS Negl Trop Dis 5: e1436.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Sudarshan M, Weirather JL, Wilson ME, Sundar S, 2011. Study of parasite kinetics with antileishmanial drugs using real-time quantitative PCR in Indian visceral leishmaniasis. J Antimicrob Chemother 66: 17511755.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    van der Meide WF, Peekel I, van Thiel PP, Schallig HD, de Vries HJ, Zeegelaar JE, Faber WR, 2008. Treatment assessment by monitoring parasite load in skin biopsies from patients with cutaneous leishmaniasis, using quantitative nucleic acid sequence-based amplification. Clin Exp Dermatol 33: 394399.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Jara M, Adaui V, Valencia BM, Martinez D, Alba M, Castrillon C, Cruz M, Cruz I, Van der Auwera G, Llanos-Cuentas A, Dujardin JC, Arevalo J, 2013. A real-time PCR assay for detection and quantification of Leishmania (Viannia) in skin and mucosal lesions: an exploratory study of parasite load and clinical parameters. J Clin Microbiol 51: 18261833.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Boggild AK, Valencia BM, Espinosa DE, Veland N, Ramos AP, Arevalo J, Llanos-Cuentas A, Low DE, 2010. Detection and species identification of Leishmania DNA from filter paper lesion impressions in patients with American cutaneous leishmaniasis. Clin Infect Dis 50: e1e6.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Sokal JE, 1975. Measurement of delayed skin-test responses. N Engl J Med 293: 501502.

  • 12.

    Lopez M, Orrego C, Cangalaya M, Inga R, Arevalo J, 1993. Diagnosis of Leishmania via the polymerase chain reaction: a simplified procedure for field work. Am J Trop Med Hyg 49: 348356.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Veland N, Boggild A, Valencia C, Valencia BM, Llanos-Cuentas A, Van der Auwera G, Dujardin JC, Arevalo J, 2012. Leishmania (Viannia) species identification on clinical samples from cutaneous leishmaniasis in Peru: assessment of a molecular step-wise approach. J Clin Microbiol 50: 495498.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Schonian G, Nasereddin A, Dinse N, Schweynoch C, Schallig HDFH, Presber W, Jaffe CL, 2003. PCR diagnosis and characterization of Leishmania in local and imported clinical samples. Diagn Microbiol Infect Dis 47: 349358.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    De Almeida ME, Steurer FJ, Koru O, Herwaldt BL, Pieniazek NJ, da Silva AJ, 2011. Identification of Leishmania spp. by molecular amplification and DNA sequencing analysis of a fragment of rRNA internal transcribed spacer 2. J Clin Microbiol 49: 3143.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Mendonça MG, de Brito ME, Rodrigues EH, Bandeira V, Jardim ML, Abath FG, 2004. Persistence of Leishmania parasites in scars after clinical cure of American cutaneous leishmaniasis: is there a sterile cure? J Infect Dis 189: 10181023.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Coutinho SG, Pirmez C, Da-Cruz AM, 2002. Parasitological and immunological follow-up of American tegumentary leishmaniasis patients. Trans R Soc Trop Med Hyg 96 (Suppl 1): S173S178.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Schubach A, Marzochi MC, Cuzzi-Maya T, Oliveira AV, Araujo ML, Oliveira AL, Pacheco RS, Momen H, Conceicao-Silva F, Coutinho SG, Marzochi KB, 1998. Cutaneous scars in American tegumentary leishmaniasis patients: a site of Leishmania (Viannia) braziliensis persistence and viability eleven years after antimonial therapy and clinical cure. Am J Trop Med Hyg 58: 824827.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Schubach A, Haddad F, Oliveira-Neto MP, Degrave W, Pirmez C, Grimaldi G Jr, Fernandes O, 1998. Detection of Leishmania DNA by polymerase chain reaction in scars of treated human patients. J Infect Dis 178: 911914.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Prina E, Roux E, Mattei D, Milon G, 2007. Leishmania DNA is rapidly degraded following parasite death: an analysis by microscopy and real-time PCR. Microbes Infect 9: 13071315.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Vanaerschot M, Dumetz F, Roy S, Ponte-Sucre A, Arevalo J, Dujardin JC, 2014. Treatment failure in leishmaniasis: drug-resistance or another (epi-) phenotype? Expert Rev Anti Infect Ther 12: 937946.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    Kloehn J, Saunders EC, O'Callaghan S, Dagley MJ, McConville MJ, 2015. Characterization of metabolically quiescent Leishmania parasites in murine lesions using heavy water labeling. PLoS Pathog 11: e1004683

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Maurya R, Singh RK, Kumar B, Salotra P, Rai M, Sundar S, 2005. Evaluation of PCR for diagnosis of Indian kala-azar and assessment of cure. J Clin Microbiol 43: 30383041.

  • 24.

    Disch J, Oliveira MC, Orsini M, Rabello A, 2004. Rapid clearance of circulating Leishmania kinetoplast DNA after treatment of visceral leishmaniasis. Acta Trop 92: 279283.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Nuzum E, White F 3rd, Thakur C, Dietze R, Wages J, Grogl M, Berman J, 1995. Diagnosis of symptomatic visceral leishmaniasis by use of the polymerase chain reaction on patient blood. J Infect Dis 171: 751754.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Saravia NG, Weigle K, Segura I, Giannini SH, Pacheco R, Labrada LA, Goncalves A, 1990. Recurrent lesions in human Leishmania braziliensis infection—reactivation or reinfection? Lancet 336: 398402.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Carvalho EM, Johnson WD, Barreto E, Marsden PD, Costa JL, Reed S, Rocha H, 1985. Cell mediated immunity in American cutaneous and mucosal leishmaniasis. J Immunol 135: 41444148.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Da-Cruz AM, Bittar R, Mattos M, Oliveira-Neto MP, Nogueira R, Pinho-Ribeiro V, Azeredo-Coutinho RB, Coutinho SG, 2002. T-cell-mediated immune responses in patients with cutaneous or mucosal leishmaniasis: long-term evaluation after therapy. Clin Diagn Lab Immunol 9: 251256.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Maretti-Mira AC, Bittner J, Oliveira-Neto MP, Liu M, Kang D, Li H, Pirmez C, Craft N, 2012. Transcriptome patterns from primary cutaneous Leishmania braziliensis infections associate with eventual development of mucosal disease in humans. PLoS Negl Trop Dis 6: e1816.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Dos Santos Nogueira R, Gomes-Silva A, de Cássia Bittar R, Silva Mendonça D, Amato VS, da Silva Mattos M, Oliveira-Neto MP, Coutinho SG, Da-Cruz AM, 2014. Antigen-triggered IFN-gamma and IL-10 pattern in cured mucosal leishmaniasis patients is shaped during the active phase of disease. Clin Exp Immunol 177: 679686.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Tuon FF, Gomes-Silva A, Da-Cruz AM, Duarte MI, Neto VA, Amato VS, 2008. Local immunological factors associated with recurrence of mucosal leishmaniasis. Clin Immunol 128: 442446.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Maurer-Cecchini A, Decuypere S, Chappuis F, Alexandrenne C, De Doncker S, Boelaert M, Dujardin JC, Loutan L, Dayer JM, Tulliano G, Arevalo J, Llanos-Cuentas A, Chizzolini C, 2009. Immunological determinants of clinical outcome in Peruvian patients with tegumentary leishmaniasis treated with pentavalent antimonials. Infect Immun 77: 20222029.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    Blum J, Lockwood DNJ, Visser L, Harms G, Bailey MS, Caumes E, Clerinx J, van Thiel PP, Morizot G, Hatz C, Buffet P, 2012. Local or systemic treatment for New World cutaneous leishmaniasis? Re-evaluating the evidence for the risk of mucosal leishmaniasis. Int Health 4: 153163.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Hodiamont CJ, Kager PA, Bart A, de Vries HJ, van Thiel PP, Leenstra T, de Vries PJ, van Vugt M, Grobusch MP, van Gool T, 2014. Species-directed therapy for leishmaniasis in returning travellers: a comprehensive guide. PLoS Negl Trop Dis 8: e2832.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Arevalo J, Ramirez L, Adaui V, Zimic M, Tulliano G, Miranda-Verástegui C, Lazo M, Loayza-Muro R, De Doncker S, Maurer A, Chappuis F, Dujardin JC, Llanos-Cuentas A, 2007. Influence of Leishmania (Viannia) species on the response to antimonial treatment in patients with American tegumentary leishmaniasis. J Infect Dis 195: 18461851.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36.

    Santrich C, Segura I, Arias AL, Saravia NG, 1990. Mucosal disease caused by Leishmania braziliensis guyanensis. Am J Trop Med Hyg 42: 5155.

  • 37.

    Osorio LE, Castillo CM, Ochoa MT, 1998. Mucosal leishmaniasis due to Leishmania (Viannia) panamensis in Colombia: clinical characteristics. Am J Trop Med Hyg 59: 4952.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38.

    Montalvo AM, Fraga J, Monzote L, Montano I, De Doncker S, Dujardin JC, Van der Auwera G, 2010. Heat-shock protein 70 PCR-RFLP: a universal simple tool for Leishmania species discrimination in the New and Old World. Parasitology 137: 11591168.

    • PubMed
    • Search Google Scholar
    • Export Citation
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