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-
1.
Alvar J, Vélez ID, Bern C, Herrero M, Desjeux P, Cano J, Jannin J, den Boer M; WHO Leishmaniasis Control Team, 2012. Leishmaniasis worldwide and global estimates of its incidence. PLoS One 7: 35671.
-
2.
Grimaldi G Jr., Tesh RB, 1993. Leishmaniasis of the New World: current concepts and implications for future research. Clin Microbiol Rev 6: 230–250.
-
3.
Silveira FT, Lainson R, Corbett CE, 2004. Clinical and immunopathological spectrum of American cutaneous leishmaniasis with special reference to the disease in Amazonian Brazil: a review. Mem Inst Oswaldo Cruz 99: 239–251.
-
4.
Barral A, Guerreiro J, Bomfim G, Correia D, Barral-Netto M, Carvalho EM, 1995. Lymphadenopathy as the first sign of human cutaneous infection by Leishmania braziliensis. Am J Trop Med Hyg 53: 256–259.
-
5.
Marsden PD, 1986. Mucosal leishmaniasis (“espundia” Escomel, 1911). Trans R Soc Trop Med Hyg 80: 859–876.
-
6.
Lessa MM, Lessa HA, Castro TW, Oliveira A, Scherifer A, Machado P, Carvalho EM, 2007. Mucosal leishmaniasis: epidemiological and clinical aspects. Rev Bras Otorrinolaringol (Engl Ed) 73: 843–847.
-
7.
Turetz ML, Machado PR, Ko AI, Alves F, Bittencourt A, Almeida RP, Mobashery N, Johnson WD Jr., Carvalho EM, 2002. Disseminated leishmaniasis: a new and emerging form of leishmaniasis observed in northeastern Brazil. J Infect Dis 186: 1829–1834.
-
8.
Aronson N, Herwaldt BL, Libman M, Pearson R, Lopez-Velez R, Weina P, Carvalho EM, Ephros M, Jeronimo S, Magill A, 2017. Diagnosis and treatment of leishmaniasis: clinical practice guidelines by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH). Clin Infect Dis 96: 24–45.
-
9.
Jirmanus L, Glesby MJ, Guimarães LH, Lago E, Rosa ME, Machado PR, Carvalho EM, 2012. Epidemiological and clinical changes in American tegumentary leishmaniasis in an area of Leishmania (Viannia) braziliensis transmission over a 20-year period. Am J Trop Med Hyg 86: 426–433.
-
10.
Diniz DS, Costa AS, Escalda PM, 2012. The effect of age on the frequency of adverse reactions caused by antimony in the treatment of American tegumentary leishmaniasis in Governador Valadares, State of Minas Gerais, Brazil. Rev Soc Bras Med Trop 45: 597–600.
-
11.
Carvalho AM, Amorim CF, Barbosa JL, Lago AS, Carvalho EM, 2015. Age modifies the immunologic response and clinical presentation of American tegumentary leishmaniasis. Am J Trop Med Hyg 92: 1173–1177.
-
12.
Bacellar O, Lessa H, Schriefer A, Machado P, Ribeiro de Jesus A, Dutra WO, Gollob KJ, Carvalho EM, 2002. Up-regulation of Th1-type responses in mucosal leishmaniasis patients. Infect Immun 70: 6734–6740.
-
13.
Machado P, Araújo C, Da Silva AT, Almeida RP, D’Oliveira A Jr., Bittencourt A, Carvalho EM, 2002. Failure of early treatment of cutaneous leishmaniasis in preventing the development of an ulcer. Clin Infect Dis 15: E69–E73.
-
14.
da Silva Santos C, Brodskyn CI, 2014. The role of CD4 and CD8 T cells in human cutaneous leishmaniasis. Front Public Health 2: 165.
-
15.
Novais FO, Carvalho AM, Clark ML, Carvalho LP, Beiting DP, Brodsky IE, Carvalho EM, Scott P, 2017. CD8+ T cell cytotoxicity mediates pathology in the skin by inflammasome activation and IL-1β production. PLoS Pathog 13: e1006196.
-
16.
Antonelli LR, Dutra WO, Almeida RP, Bacellar O, Carvalho EM, Gollob KJ, 2005. Activated inflammatory T cells correlate with lesion size in human cutaneous leishmaniasis. Immunol Lett 15: 226–230.
-
17.
Giudice A, Vendrame C, Bezerra C, Carvalho LP, Delavechia T, Carvalho EM, Bacellar O, 2012. Macrophages participate in host protection and the disease pathology associated with Leishmania braziliensis infection. BMC Infect Dis 12: 75.
-
18.
Cardoso TM, Machado Á, Costa DL, Carvalho LP, Queiroz A, Machado P, Scott P, Carvalho EM, Bacellar O, 2014. Protective and pathological functions of CD8+ T cells in Leishmania braziliensis infection. Infect Immun 83: 898–906.
-
19.
Barral A, Costa JM, Bittencourt AL, Barral-Netto M, Carvalho EM, 1995. Polar and subpolar diffuse cutaneous leishmaniasis in Brazil: clinical and immunopathologic aspects. Int J Dermatol 34: 474–479.
-
20.
Machado PR, Lessa H, Lessa M, Guimarães LH, Bang H, Ho JL, Carvalho EM, 2007. Oral pentoxifylline combined with pentavalent antimony: a randomized trial for mucosal leishmaniasis. Clin Infect Dis 44: 788–793.
-
21.
Oliveira-Neto MP, Schubach A, Mattos M, Goncalves-Costa SC, Pirmez C, 1997. A low-dose antimony treatment in 159 patients with American cutaneous leishmaniasis: extensive follow-up studies (up to 10 years). Am J Trop Med Hyg 57: 651–655.
-
22.
Arevalo J et al. 2007. Influence of Leishmania (Viannia) species on the response to antimonial treatment in patients with American tegumentary leishmaniasis. J Infect Dis 15: 1846–1851.
-
23.
Unger A, O’Neal S, Machado PR, Guimarães LH, Morgan DJ, Schriefer A, Bacellar O, Glesby MJ, Carvalho EM, 2009. Association of treatment of American cutaneous leishmaniasis prior to ulcer development with high rate of failure in northeastern Brazil. Am J Trop Med Hyg 80: 574–579.
-
24.
Correia D, Macêdo VO, Carvalho EM, Barral A, Magalhães AV, de Abreu MV, Orge ML, Marsden P, 1996. Comparative study of meglumine antimoniate, pentamidine isethionate and aminosidine sulfate in the treatment of primary skin lesions caused by Leishmania (Viannia) braziliensis. Rev Soc Bras Med Trop 29: 447–453.
-
25.
O’Neal SE, Guimarães LH, Machado PR, Alcântara L, Morgan DJ, Passos S, Glesby MJ, Carvalho EM, 2007. Influence of helminth infections on the clinical course of and immune response to Leishmania braziliensis cutaneous leishmaniasis. J Infect Dis 1: 142–148.
-
26.
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.
-
27.
Prates FV, Dourado ME, Silva SC, Schriefer A, Guimarães LH, Brito MD, Almeida J, Carvalho EM, Machado PR, 2017. Fluconazole in the treatment of cutaneous leishmaniasis caused by Leishmania braziliensis: a randomized controlled trial. Clin Infect Dis 64: 67–71.
-
28.
Weirather JL et al. 2011. Serial quantitative PCR assay for detection, species discrimination, and quantification of Leishmania spp. in human samples. J Clin Microbiol 49: 3892–3904.
-
29.
Sousa Ade Q, Parise ME, Pompeu MM, Coehlo Filho JM, Vasconcelos IA, Lima JW, Oliveira EG, Vasconcelos AW, David JR, Maguire JH, 1995. Bubonic leishmaniasis: a common manifestation of Leishmania (Viannia) braziliensis infection in Ceara, Brazil. Am J Trop Med Hyg 53: 380–385.
-
30.
Reed SG, Andrade ZA, Roters SB, Inverso JA, Sadigursky M, 1986. Leishmania mexicana amazonensis em camundongos endogâmicos “resistentes” após a remoção do linfonodo drenante. Clin Exp Immunol 64: 8–13.
-
31.
Oliveira-Neto MP, Mattos MS, Perez MA, Da-Cruz AM, Fernandes O, Moreira J, Gonçalves-Costa SC, Brahin LR, Menezes CR, Pirmez C, 2000. American tegumentary leishmaniasis (ATL) in Rio de Janeiro State, Brazil: main clinical and epidemiologic characteristics. Int J Dermatol 39: 506–514.
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Andersen EM, Cruz-Saldarriaga M, Llanos-Cuentas A, Luz-Cjuno M, Echevarria J, Miranda-Verastegui C, Colina O, Berman JD, 2005. Comparison of meglumine antimoniate and pentamidine for peruvian cutaneous leishmaniasis. Am J Trop Med Hyg 72: 133–137.
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The Elderly Respond to Antimony Therapy for Cutaneous Leishmaniasis Similarly to Young Patients but Have Severe Adverse Reactions
Alexsandro Souza do Lago
Alexsandro Souza do Lago
Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil;
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Maurício Nascimento
Maurício Nascimento
Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil;
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Augusto M. Carvalho
Augusto M. Carvalho
Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil;
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Neuza Lago
Neuza Lago
Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil;
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Juliana Silva
Juliana Silva
Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil;
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José Roberto Queiroz
José Roberto Queiroz
Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil;
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Lucas P. Carvalho
Lucas P. Carvalho
Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil;
CNPq/MCT, Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Salvador, Brazil;
Laboratório de Pesquisas Clínicas do Instituto Gonçalo Moniz (IGM), Fiocruz, Salvador, Brazil;
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CNPq/MCT, Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Salvador, Brazil;
Laboratório de Pesquisas Clínicas do Instituto Gonçalo Moniz (IGM), Fiocruz, Salvador, Brazil;
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Albert Schriefer
Albert Schriefer
Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil;
CNPq/MCT, Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Salvador, Brazil;
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CNPq/MCT, Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Salvador, Brazil;
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Mary Wilson
Mary Wilson
Department of Internal Medicine, University of Iowa, Iowa City, Iowa
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Paulo Machado
Paulo Machado
Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil;
CNPq/MCT, Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Salvador, Brazil;
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CNPq/MCT, Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Salvador, Brazil;
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Edgar M. Carvalho
Edgar M. Carvalho
Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil;
CNPq/MCT, Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Salvador, Brazil;
Laboratório de Pesquisas Clínicas do Instituto Gonçalo Moniz (IGM), Fiocruz, Salvador, Brazil;
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CNPq/MCT, Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Salvador, Brazil;
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There is evidence that elderly patients with cutaneous leishmaniasis (CL) have more mucosal and disseminated diseases than young patients and their cells produce less antigen-induced interferon (IFN)-γ. Herein, we compared the roles of interleukin (IL)-10 and IL-15 as modulators of antigen-induced immune responses and the incidence of adverse reaction and response to therapy in young versus elderly patients with CL. Study participants included 35 senior (60–85 years) and 35 young (18–40 years) patients who had a diagnosis of CL documented by typical cutaneous lesions containing Leishmania braziliensis DNA. Elderly patients had less lymph node enlargement. Antigen-induced blood cell cytokine responses were studied in the absence or presence of IL-10 antibody or exogenously added recombinant IL-15. The ratio of IFN-γ/IL-10 was lower in elderly patients, and IFN-γ production was enhanced by either neutralization of IL-10 or exogenous recombinant IL-15 in blood cells from elderly but not young patients. Patients were treated three times weekly with antimony at 20 mg/kg/day for 20 doses. Although there was no difference in response to therapy between the two groups, two young patients needed rescue therapy with amphotericin B. Ventricular arrhythmias and ventricular overload were more frequent in elderly patients. We conclude that elderly patients have alterations in the immune response that may influence clinical manifestations, but we did not find that they had a higher failure rate than young subjects to antimony therapy. However, because of the high rate of electrocardiographic abnormalities during therapy, antimony should not be used in elderly patients with CL.
Author Notes
Financial support: This work was supported by the National Institutes of Health (NIH) grant U01-AI136032.
Authors’ addresses: Alexsandro Souza do Lago, Augusto M. Carvalho, Neuza Lago, Juliana Silva, and Paulo Machado, Serviço de Imunologia, Universidade Federal da Bahia, Salvador, Brazil, E-mails: alex-lago@hotmail.com, augustomarcelino1@hotmail.com, neu.lago@yahoo.com.br, july_meida@yahoo.com.br, and prlmachado@uol.com.br. Maurício Nascimento and José Roberto Queiroz, Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil, E-mails: mauriciotnascimento@hotmail.com and jrabreu@cardiol.br. Lucas P. Carvalho, Serviço de Imunologia, Universidade Federal da Bahia, Salvador, Brazil, and Laboratório de Pesquisas Clínicas do Instituto Gonçalo Moniz, Salvador, Brazil, E-mail: carvalholp76@gmail.com. Albert Schriefer, Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Salvador, Brazil, E-mail: aschriefer@ufba.br. Mary Wilson, Department of Internal Medicine and Microbiology, University of Iowa, Iowa City, IA, E-mail: mary-wilson@uiowa.edu. Edgar M. Carvalho, Servico de Imunologia, Federal University of Bahia, Salvador, Brazil, and Laboratório de Pesquisas Clínicas, Instituto Gonçalo Moniz, Salvador, Brazil, E-mail: imuno@ufba.br.
ProCite
RefWorks
Reference Manager
BibTeX
Zotero
EndNote
-
1.
Alvar J, Vélez ID, Bern C, Herrero M, Desjeux P, Cano J, Jannin J, den Boer M; WHO Leishmaniasis Control Team, 2012. Leishmaniasis worldwide and global estimates of its incidence. PLoS One 7: 35671.
-
2.
Grimaldi G Jr., Tesh RB, 1993. Leishmaniasis of the New World: current concepts and implications for future research. Clin Microbiol Rev 6: 230–250.
-
3.
Silveira FT, Lainson R, Corbett CE, 2004. Clinical and immunopathological spectrum of American cutaneous leishmaniasis with special reference to the disease in Amazonian Brazil: a review. Mem Inst Oswaldo Cruz 99: 239–251.
-
4.
Barral A, Guerreiro J, Bomfim G, Correia D, Barral-Netto M, Carvalho EM, 1995. Lymphadenopathy as the first sign of human cutaneous infection by Leishmania braziliensis. Am J Trop Med Hyg 53: 256–259.
-
5.
Marsden PD, 1986. Mucosal leishmaniasis (“espundia” Escomel, 1911). Trans R Soc Trop Med Hyg 80: 859–876.
-
6.
Lessa MM, Lessa HA, Castro TW, Oliveira A, Scherifer A, Machado P, Carvalho EM, 2007. Mucosal leishmaniasis: epidemiological and clinical aspects. Rev Bras Otorrinolaringol (Engl Ed) 73: 843–847.
-
7.
Turetz ML, Machado PR, Ko AI, Alves F, Bittencourt A, Almeida RP, Mobashery N, Johnson WD Jr., Carvalho EM, 2002. Disseminated leishmaniasis: a new and emerging form of leishmaniasis observed in northeastern Brazil. J Infect Dis 186: 1829–1834.
-
8.
Aronson N, Herwaldt BL, Libman M, Pearson R, Lopez-Velez R, Weina P, Carvalho EM, Ephros M, Jeronimo S, Magill A, 2017. Diagnosis and treatment of leishmaniasis: clinical practice guidelines by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH). Clin Infect Dis 96: 24–45.
-
9.
Jirmanus L, Glesby MJ, Guimarães LH, Lago E, Rosa ME, Machado PR, Carvalho EM, 2012. Epidemiological and clinical changes in American tegumentary leishmaniasis in an area of Leishmania (Viannia) braziliensis transmission over a 20-year period. Am J Trop Med Hyg 86: 426–433.
-
10.
Diniz DS, Costa AS, Escalda PM, 2012. The effect of age on the frequency of adverse reactions caused by antimony in the treatment of American tegumentary leishmaniasis in Governador Valadares, State of Minas Gerais, Brazil. Rev Soc Bras Med Trop 45: 597–600.
-
11.
Carvalho AM, Amorim CF, Barbosa JL, Lago AS, Carvalho EM, 2015. Age modifies the immunologic response and clinical presentation of American tegumentary leishmaniasis. Am J Trop Med Hyg 92: 1173–1177.
-
12.
Bacellar O, Lessa H, Schriefer A, Machado P, Ribeiro de Jesus A, Dutra WO, Gollob KJ, Carvalho EM, 2002. Up-regulation of Th1-type responses in mucosal leishmaniasis patients. Infect Immun 70: 6734–6740.
-
13.
Machado P, Araújo C, Da Silva AT, Almeida RP, D’Oliveira A Jr., Bittencourt A, Carvalho EM, 2002. Failure of early treatment of cutaneous leishmaniasis in preventing the development of an ulcer. Clin Infect Dis 15: E69–E73.
-
14.
da Silva Santos C, Brodskyn CI, 2014. The role of CD4 and CD8 T cells in human cutaneous leishmaniasis. Front Public Health 2: 165.
-
15.
Novais FO, Carvalho AM, Clark ML, Carvalho LP, Beiting DP, Brodsky IE, Carvalho EM, Scott P, 2017. CD8+ T cell cytotoxicity mediates pathology in the skin by inflammasome activation and IL-1β production. PLoS Pathog 13: e1006196.
-
16.
Antonelli LR, Dutra WO, Almeida RP, Bacellar O, Carvalho EM, Gollob KJ, 2005. Activated inflammatory T cells correlate with lesion size in human cutaneous leishmaniasis. Immunol Lett 15: 226–230.
-
17.
Giudice A, Vendrame C, Bezerra C, Carvalho LP, Delavechia T, Carvalho EM, Bacellar O, 2012. Macrophages participate in host protection and the disease pathology associated with Leishmania braziliensis infection. BMC Infect Dis 12: 75.
-
18.
Cardoso TM, Machado Á, Costa DL, Carvalho LP, Queiroz A, Machado P, Scott P, Carvalho EM, Bacellar O, 2014. Protective and pathological functions of CD8+ T cells in Leishmania braziliensis infection. Infect Immun 83: 898–906.
-
19.
Barral A, Costa JM, Bittencourt AL, Barral-Netto M, Carvalho EM, 1995. Polar and subpolar diffuse cutaneous leishmaniasis in Brazil: clinical and immunopathologic aspects. Int J Dermatol 34: 474–479.
-
20.
Machado PR, Lessa H, Lessa M, Guimarães LH, Bang H, Ho JL, Carvalho EM, 2007. Oral pentoxifylline combined with pentavalent antimony: a randomized trial for mucosal leishmaniasis. Clin Infect Dis 44: 788–793.
-
21.
Oliveira-Neto MP, Schubach A, Mattos M, Goncalves-Costa SC, Pirmez C, 1997. A low-dose antimony treatment in 159 patients with American cutaneous leishmaniasis: extensive follow-up studies (up to 10 years). Am J Trop Med Hyg 57: 651–655.
-
22.
Arevalo J et al. 2007. Influence of Leishmania (Viannia) species on the response to antimonial treatment in patients with American tegumentary leishmaniasis. J Infect Dis 15: 1846–1851.
-
23.
Unger A, O’Neal S, Machado PR, Guimarães LH, Morgan DJ, Schriefer A, Bacellar O, Glesby MJ, Carvalho EM, 2009. Association of treatment of American cutaneous leishmaniasis prior to ulcer development with high rate of failure in northeastern Brazil. Am J Trop Med Hyg 80: 574–579.
-
24.
Correia D, Macêdo VO, Carvalho EM, Barral A, Magalhães AV, de Abreu MV, Orge ML, Marsden P, 1996. Comparative study of meglumine antimoniate, pentamidine isethionate and aminosidine sulfate in the treatment of primary skin lesions caused by Leishmania (Viannia) braziliensis. Rev Soc Bras Med Trop 29: 447–453.
-
25.
O’Neal SE, Guimarães LH, Machado PR, Alcântara L, Morgan DJ, Passos S, Glesby MJ, Carvalho EM, 2007. Influence of helminth infections on the clinical course of and immune response to Leishmania braziliensis cutaneous leishmaniasis. J Infect Dis 1: 142–148.
-
26.
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.
-
27.
Prates FV, Dourado ME, Silva SC, Schriefer A, Guimarães LH, Brito MD, Almeida J, Carvalho EM, Machado PR, 2017. Fluconazole in the treatment of cutaneous leishmaniasis caused by Leishmania braziliensis: a randomized controlled trial. Clin Infect Dis 64: 67–71.
-
28.
Weirather JL et al. 2011. Serial quantitative PCR assay for detection, species discrimination, and quantification of Leishmania spp. in human samples. J Clin Microbiol 49: 3892–3904.
-
29.
Sousa Ade Q, Parise ME, Pompeu MM, Coehlo Filho JM, Vasconcelos IA, Lima JW, Oliveira EG, Vasconcelos AW, David JR, Maguire JH, 1995. Bubonic leishmaniasis: a common manifestation of Leishmania (Viannia) braziliensis infection in Ceara, Brazil. Am J Trop Med Hyg 53: 380–385.
-
30.
Reed SG, Andrade ZA, Roters SB, Inverso JA, Sadigursky M, 1986. Leishmania mexicana amazonensis em camundongos endogâmicos “resistentes” após a remoção do linfonodo drenante. Clin Exp Immunol 64: 8–13.
-
31.
Oliveira-Neto MP, Mattos MS, Perez MA, Da-Cruz AM, Fernandes O, Moreira J, Gonçalves-Costa SC, Brahin LR, Menezes CR, Pirmez C, 2000. American tegumentary leishmaniasis (ATL) in Rio de Janeiro State, Brazil: main clinical and epidemiologic characteristics. Int J Dermatol 39: 506–514.
-
32.
Andersen EM, Cruz-Saldarriaga M, Llanos-Cuentas A, Luz-Cjuno M, Echevarria J, Miranda-Verastegui C, Colina O, Berman JD, 2005. Comparison of meglumine antimoniate and pentamidine for peruvian cutaneous leishmaniasis. Am J Trop Med Hyg 72: 133–137.
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33.
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