15
Mucosal Leishmaniasis (CL)
44. All persons with clinically manifest, metastatic, American ML
should receive systemic antileishmanial therapy, with the goals of
preventing morbidity (eg, disfigurement) and mortality (eg, from
aspiration pneumonia or respiratory obstruction) (S-L).
45. Before treatment is initiated, a complete examination of the naso-
oropharyngeal/laryngeal mucosa should be conducted by a specialist
to assess the anatomic extension and clinical severity of the mucosal
disease, which have prognostic implications (S-M).
46. The Panel recommends inpatient monitoring and prophylactic
corticosteroid therapy for persons with laryngeal/pharyngeal disease
and increased risk for respiratory obstruction, as indicated by
symptoms and otolaryngologic/radiologic examinations, because
of the potential for inflammatory reactions after initiation of
antileishmanial therapy (S-L).
47. The choice of antileishmanial agent, dose, and duration of therapy for
persons with ML should be individualized (Table 3) (S-M).
Remarks: The traditional options for ML include treatment with a pentavalent
antimonial (SbV) compound (20 mg SbV/kg daily, IV or IM, for 28–30 days)
or with amphotericin B deoxycholate (0.5–1.0 mg/kg per dose, IV, daily or every
other day, for a cumulative total of ~20–45 mg/kg ). More recently, on the basis
of comparatively limited data, the armamentarium has expanded to include lipid
formulations of amphotericin B (typically, liposomal amphotericin B [L-AmB], with
a cumulative total dose ranging widely from ~20–60 mg/kg ), as well as the oral agent
miltefosine (~2.5 mg/kg per day [maximum, 150 mg/day] for28 days).
Visceral Leishmaniasis (VL)
VL is potentially life threatening and requires prompt evaluation and treatment. The
potential for VL to be life threatening and the high response rate associated with
L-AmB therapy justify its side effects and cost.
The objective of treatment is clinical healing, not parasitologic cure. Treatment does
not necessarily result in parasitologic cure, as evidenced by cases of relapse, especially
in the context of immunosuppression.
Some experts consider all persons with symptomatic VL to be immunocompromised,
some perhaps without an identified immune defect. (In these guidelines,
immunocompetent VL refers to persons with VL without an identified immune
defect.)
48. The Panel recommends that persons with clinical abnormalities
compatible with VL and laboratory evidence of VL be treated
(Table 3) (S-M).
