Hindawi Publishing Corporation

Case Reports in Veterinary Medicine

Volume 2014, Article ID 640151, 6 pages
http://dx.doi.org/10.1155/2014/640151

Case Report
Failure of Miltefosine Treatment in Two Dogs with Natural
Leishmania infantum Infection

Daniela Proverbio, Eva Spada, Giada Bagnagatti De Giorgi, and Roberta Perego
Dipartimento di Scienze Veterinarie per la Salute, la Produzione Animale e la Sicurezza Alimentare, Università degli Studi di Milano,
Via G. Celoria, 10-20133 Milano, Italy

Correspondence should be addressed to Daniela Proverbio; [email protected]

Received 18 April 2014; Revised 7 July 2014; Accepted 23 July 2014; Published 14 August 2014

Academic Editor: Katerina K. Adamama-Moraitou

Copyright © 2014 Daniela Proverbio et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Two dogs, with naturally acquired canine leishmaniasis, were treated orally with miltefosine (2 mg/kg q 24 hr) and allopurinol
(10 mg/kg q 12 hr) for 28 days. Both dogs showed good initial response to therapy, with reduction in clinical signs and improvement
of clinicopathological changes. However, in both dogs, clinical and clinicopathological abnormalities recurred 150 days after initial
treatment and a second course of miltefosine and allopurinol was administered. One dog failed to respond to the 2nd cycle of
miltefosine treatment and the other dog responded initially but suffered an early relapse. Treatment with meglumine antimoniate
(100 mg/kg q 24 hr for a minimum of 4 weeks) was then started in both dogs. Both dogs showed rapid clinical and clinicopathological
improvement and to date they have not received further treatment for 420 and 270 days, respectively. In view of the low number of
antileishmanial drugs available and the fact that some of these are used in human as well as veterinary medicine, it is of paramount
importance that drug resistance is monitored and documented.

1. Introduction ocular lesions, epistaxis, and onychogryphosis. Laboratory

findings include nonregenerative anemia, serum hyperpro-
Canine leishmaniasis (CanL) caused by the protozoan teinemia, polyclonal beta and gamma hyperglobulinemia,
Leishmania infantum is a life threatening zoonotic dis- hypoalbuminemia, decreased albumin/globulin ratio, renal
ease transmitted by insect vectors, sand flies (Phleboto-
azotemia, and persistent renal proteinuria [3].
mus spp.). CanL has a wide distribution in temperate and
subtropical countries with a very wide prevalence cover- The antileishmanial drugs currently used in dogs were
ing both the old and new worlds. The dog is the main originally developed to treat leishmaniasis in people, and
reservoir for human visceral leishmaniasis (VL) caused most therapeutic protocols were developed through human
by Leishmania infantum [1] which is listed among the clinical studies with subsequent adaption for use in dogs
most important neglected tropical diseases by the WHO [4]. Many drugs (including amphotericin B, pentamidine,
(http://www.who.int/neglected disease/diseases; access April metronidazole, spiramycin, enrofloxacin, and ketoconazole)
2014). have been used, either alone or in combination, with variable
The clinical features of CanL vary widely as a consequence results [4–7]. Currently, the first line treatment against CanL
of the numerous pathogenic mechanisms involved in the is meglumine antimoniate (MA), usually in combination
disease, the different organs affected, and the diverse nature of with allopurinol [7]. This treatment protocol usually induces
the immune responses mounted by individual hosts [2]. The clinical remission, although it does not prevent relapses and
main clinical findings include skin lesions (such as exfolia- in most cases does not completely eliminate parasites from
tive dermatitis, papules, nodules, ulcerations, and alopecia), the infected animal [8].
generalized lymphadenomegaly, splenomegaly, progressive Recently, miltefosine (MLF) (in combination with allop-
weight loss, muscular atrophy, polyuria and polydipsia, urinol) has been suggested as an alternative to meglumine
 1792, 2014, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2014/640151 by UECE - Universidade Estadual do Ceara, Wiley Online Library on [02/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2 Case Reports in Veterinary Medicine

Table 1: Case number 1: clinical score, therapy, and hematological and biochemical analysis of the first dog affected by canine leishmaniasis.

Followup Clinical score RBC Hb PCV% PLT TP ALB% 𝛾G% A/G IFAT
Therapy
×103 /𝜇L g/dL /uL g/dL
D0 8/86 MLT + A 34.8 31.7 42.7 0.46 1 : 1280
5220 12.6 37.000 9.3
28/d
D30 3/86 A 5840 12.6 34.5 15.000 7.8 35.2 37.6 0.54 1 : 640
D60 2/86 A 6440 14.3 38.7 65.000 7.5 42.9 25.6 0.75 1 : 320
D90 0/86 A 6110 13.9 37.1 149.000 7.4 42.1 21.4 0.75 1 : 320
D150 11/86 MLT + A 40.5 41 31.7 0.6 1 : 640
6350 14.2 232.000 8.3
28/d
D 210 0/86 A 6220 13.9 43.3 138.000 7.6 49.3 11.4 0.97 1 : 160
D240 2/86 MA 42.5 38.6 20.3 0.63 1 : 320
6160 15 68.000 6.8
28gg
D270 0/86 A 5750 13.2 35.2 151.000 5.8 46.7 10.4 0.88 1 : 160
D330 0/86 A 6420 15.7 38.9 116.000 6.7 46.1 10 0.86 1 : 160
D390 0/86 A 6560 14 40.2 174.000 7.1 47.5 8.9 0.9 1 : 160
D660 1/86 — 6100 13.8 36.8 215.000 6.4 46.2 9.8 0.86 1 : 160

antimoniate for the treatment of CanL [9–13]. MLF is an hepatitis (ICH), but not treated against endo- and ectopara-
alkyphospholipid originally developed as a topical and oral sites. The dog was referred to the Internal Medicine Service of
antineoplastic agent [8]. Multiple in vivo and in vitro trials the Department of Health, Animal Science and Food Safety
have demonstrated the leishmanial killing activity of milte- of the University of Milan, with a 30-day history of erythema
fosine [12] through disruption of both signaling pathways and exfoliative dermatitis that had not responded to antibiotic
and cell membrane synthesis, which induces an apoptosis- therapy (cephalexin, ICF vet 20 mg/kg q 12 hr for 15 days).
like cell death. In people, MLF is an effective oral drug for Physical examination revealed a generalized lymphade-
the treatment of leishmaniasis although, in common with nopathy, dry, nonpruritic dermatitis with generalized scaling
other antileishmanial drugs, some reports suggest possible and alopecia of the auricular pinna, eyelids, axilla, and groin.
development of resistance [14–16]. Some studies in dogs have A provisional diagnosis of canine leishmaniasis was made.
reported the short-term efficacy of MLF therapy in associ- A blood count revealed a mild normochromic, anemia, and
ation with allopurinol and suggest that this combination is thrombocytopenia. Biochemical analysis showed hyperpro-
a safe, convenient, and effective alternative treatment option teinemia with hypoalbuminemia and hypergammaglobuline-
for canine leishmaniasis which has only mild (and self- mia. Serum protein electrophoresis showed a polyclonal
limiting) side effects [9–12]. Recent studies have reported gammopathy and a decreased albumin-globulin ratio (A/G)
cases where relapse of clinical CanL occurs between 3 and ratio (Table 1).
6 months after cessation of treatment, in dogs treated with The serum indirect immunofluorescence antibody test
a combination of MLF and allopurinol, but no data has been (IFAT) for Leishmania infantum specific antibodies yielded a
provided on the outcome of further treatments in these cases high positive titer of 1 : 1280 (reference range, <1 : 80) and con-
[9, 11]. ventional polymerase chain reaction (PCR) analysis of blood
In this paper, we describe two dogs with naturally occur- was positive for L. infantum. Indirect immunofluorescence
ring CanL that, after an initially successful treatment with assay (IFAT) for Ehrlichia canis was negative.
two cycles of MLF and allopurinol, relapsed, but subsequently Diagnosis of CanL was made and the severity of clinical
responded to further treatment with meglumine antimoniate. signs attributable to Leishmania infection was scored on a
These cases demonstrate that a failure of therapeutic response scale from 0 to 3 for a total of 86/86 (Table 2). The clinical
to MLT therapy, as has been reported in human patients, score of the case 1 was 8/86 at diagnosis. Treatment was
may also occur in dogs. Resistance surveillance is particularly started with 2 mg/kg q 24 hr of MLF per os in combination
important because the same drugs are used in dogs and with allopurinol at 10 mg/kg q 12 hr for 28 days. After the
human patients although, in Europe, miltefosine is not combined therapy, allopurinol was continued at the same
typically used to treat human visceral leishmaniasis. dosage until the last follow-up (D390).
Complete clinical and blood examination was performed
2. Case Reports at 30, 60, 90, and 150 days from the start of treatment with
MLF. Results of follow-up clinical scores, blood examina-
Case Number 1. A 1-year-old, 10.7 kg, neutered female mixed- tions, and biochemical analysis are shown in Table 2.
breed dog, adopted 4 months previously from a kennel in After the first cycle of therapy, the clinical score showed a
Sicily (a region in which canine leishmaniasis is endemic), gradual and constant decline. The anemia and the thrombo-
fully vaccinated against canine distemper virus (CDV), cytopenia resolved during the first 90 days of followup and
canine parvovirus (CPV), leptospirosis, and infectious canine gamma globulin declined. At D150, the dog was presented
 1792, 2014, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2014/640151 by UECE - Universidade Estadual do Ceara, Wiley Online Library on [02/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Case Reports in Veterinary Medicine 3

Table 2: Score for clinical parameters (on a scale from 0 to 86) used in dogs affected by canine leishmaniasis.

Clinical sign 0 1 2 3
Appetite Normal Slight decrease Moderate decrease Anorexia
Mentation Normal Slight depression Depression Prostration
Lethargy No Slight Moderate Refusal to move
Weight loss No Slight Moderate Severe
Polyuria No Slight Moderate Severe
Polydipsia No Slight Moderate Severe
Localized muscular
atrophy (temporal No Slight Moderate Severe
muscles)
Generalized muscular No Slight Moderate Severe
atrophy
Lymphadenomegaly No 1-2 nodes 2 > 4 nodes Generalized
Splenomegaly No Yes
Conjunctivitis and/or No Bilateral or unilateral
Unilateral and slight Bilateral and severe
blepharitis severe
No Bilateral or unilateral
Uveitis and/or keratitis Unilateral and slight Bilateral and severe
severe
Pale mucous membranes No Slight Moderate Severe
Epistaxis Never presented Sporadic Frequent Incoercible
No 1 or 2 small ulcers or >2 small ulcers or >1/4 or oral mouth cover
Mouth ulcers or nodules
nodules nodules by ulcers or nodules
Vomiting No Sporadic Frequent Frequent with blood
Diarrhea No Sporadic Frequent Constant
Lameness No Sporadic Frequent Constant
Itching No Sporadic Frequent Constant
<10% body surface or 10–25% body surface or
Erythema No slight generalized moderate generalized >25% body surface
erythema erythema
<10% body surface or 10–25% body surface or
Dry exfoliative No slight generalized moderate generalized >25% body surface
dermatitis
erythema erythema
Ulcerative dermatitis No 1-2 ulcers 3–5 ulcers >5 ulcers
Nodular dermatitis No 1-2 nodules 3–5 nodules >5 nodules
Sterile pustular No 1-2 pustules 3–5 pustules >5 pustules
dermatitis
10–25% body surface
Alopecia No <10% body surface >25% body surface
erythema
Altered pigmentation No Localized Multifocal Generalized
Hyperkeratosis of nasal No Slight Moderate Severe
planum and pads
Generalized No Slight Moderate Severe
hyperkeratosis
Onychogryphosis No Slight Moderate Severe

with a clinical deterioration (clinical score 11/86) and wors- Following the classification by Oliva et al. (2010) [4], the
ening of hematological parameters. A relapse was diagnosed dog was classified as “early relapse” and treatment with an
and a second 28-day cycle of MLF in combination with alternative drug was initiated.
allopurinol at the same dose as in the first cycle was started. Therapy with meglumine antimoniate (100 mg/kg/sc) in
Following the second treatment with MLF, clinical signs combination with allopurinol (10 mg/kg/q 12 hr per os) for at
were resolved at D210 (clinical score 0/86) with improvement least 4 weeks was started.
of clinicopathological abnormalities, but, at D240, the dog At D270, after 4 weeks of therapy, the dog had a clinical
showed again clinicopathological signs (clinical score 2/86). score of 0/86, biochemical analysis showed low total protein,
 1792, 2014, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2014/640151 by UECE - Universidade Estadual do Ceara, Wiley Online Library on [02/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
4 Case Reports in Veterinary Medicine

Table 3: Case number 2: clinical score, therapy, and hematological and biochemical analysis of the second dog affected by canine
leishmaniasis.

Follow-up Clinical score RBC Hb PCV% PLT TP ALB% 𝛾G% A/G IFAT
Therapy
×103 /𝜇L g/dL /uL g/dL
D0 11/86 MLT + A 32 35.5 30.1 0.5 1 : 640
5100 11.9 288.000 7.8
28/d
D30 7/86 A 5360 12.7 32.5 272.000 8.3 36.1 25.5 0.6 1 : 640
D90 3/86 A 6550 15.4 40.4 186.000 6.4 41.2 17.6 0.7 1 : 320
D150 7/86 MLT + A 37.3 33.7 24.7 0.5 1 : 320
5970 13.9 172.000 7.2
28/d
D180 11/86 MA 26.3 37.6 26.4 0.6 1 : 320
4280 8.9 295.000 8
28/d
D210 5/86 A 6470 15.3 41.2 197.000 5.9 32 19.8 0.5 1 : 320
D270 2/86 A 6700 14.6 40.2 307.000 7.4 38.6 14.7 0.63 1 : 160
D450 0/86 A 6760 14.5 42.7 230.000 6.9 46.3 13.9 0.7 1 : 160
RBC: red cells × 10/𝜇L (reference range 5700–8800 × 10/𝜇L).
Hemoglobin: Hb (reference range: 12.9–18.4 g/dL).
Haematocrit: PCV (reference range: 37.1–57%).
Platelet: PLT (reference range: 143300–400000/uL).
Total protein: TP (reference range: 6–8 g/dL).
Albumine: ALB (reference range: 46.3–58.5%).
Gamma globuline: 𝛾G (reference range: 5.3–9.9%).
Albumine/globuline: A/G (reference rang: 0.8–1.7).
IFAT: immunofluorescence antibody test (reference range: <1 : 80).
Miltefosine: MLT.
Allopurinol: A.
Meglumine antimoniate: MA.
Days: d.

gamma globulin values were close to normal range, and the positive titer of 1 : 640 (reference range, <1 : 80) and conven-
IFAT titer decreased at 1 : 160. tional polymerase chain reaction (PCR) analysis of blood was
At examinations performed at D330, D390, and D660 positive for L. infantum. Indirect immunofluorescence assays
(15 months after completing antimonial therapy), the dog (IFAT) for Ehrlichia canis were negative.
was asymptomatic and no abnormalities were present on Diagnosis of CanL was made and treatment with oral
complete blood examination and urinalysis, whilst the IFAT administration of 2 mg/kg q 24 hr of MLF in combination
titer was stable at 1 : 160. Allopurinol was discontinued 6 with allopurinol at 10 mg/kg q 12 hr for 28 days was started
months after the end of antimonial therapy. and follow-up examinations were performed at days 30, 60,
Case Number 2. A 10-year-old male Yorkshire terrier, 90, and 150. Results of follow-up clinical scores and blood
3.6 kg, was referred to the Internal Medicine Service of the biochemical examinations are shown in Table 3.
Department of Health, Animal Science and Food Safety of Following the initial treatment with MLF at D30, the
the University of Milan with an 8-month history of weight dog showed weight gain and resolution of lymphadenopa-
loss, generalized scaling, and alopecia not responding to thy, although the alopecia, dry exfoliative dermatitis, and
shampoo therapy. The dog had previously visited the south onychogryphosis persisted (clinical score 7/86). At D90, a
of Italy (Sicily Island), a region where canine leishmaniasis general clinical improvement was seen (clinical score 3/86)
is endemic. Prophylaxis had been given for ectoparasites and the only clinicopathological abnormality was hypergam-
(fipronil and s-methoprene) but not for sandfly vectors of maglobulinemia and an increase of A/G. At D150, the dog
CanL. Physical examination revealed a poor body condition, presented with recurrence of clinical signs (clinical score
depression, generalized lymphadenopathy, exfoliative, dry, 7/86): extreme lethargy, dry and exfoliative dermatitis, and
nonpruritic dermatitis with alopecia and scales on the entire increased hypergammaglobulinemia. A relapse of CanL was
head, back and limbs, and onychogryphosis (clinical score diagnosed and a second cycle of MLF in combination with
11/86). The presence of dermatophytosis or demodicosis was allopurinol was started.
excluded by both negative hair culture and negative deep skin Following the second treatment, with MLF, there was
scrapings followed by antiparasitic treatment. A blood count no clinical improvement by D180. The dog suffered further
revealed mild normocytic hypochromic anemia. Biochemical weight loss and showed lymphadenopathy, diffuse hair loss
analysis showed polyclonal hypergammaglobulinemia and and crusting lesions (clinical score 11/86), and hematological
hypoalbuminemia (Table 3). abnormalities (Table 3). On the basis of the lack of improve-
The serum indirect immunofluorescence antibody test ment in both clinical score and laboratory tests, the dog was
(IFAT) for L. infantum-specific antibodies yielded a high classified as “unresponsive” [3] and meglumine antimoniate
 1792, 2014, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2014/640151 by UECE - Universidade Estadual do Ceara, Wiley Online Library on [02/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Case Reports in Veterinary Medicine 5

therapy was started at a dose of 100 mg/kg/q 24 hr sc in (approximately 150 hours) which makes it highly susceptible
combination with allopurinol at a dose of 10 mg/kg q 12 hr to the development of resistance [21].
for at least 4 weeks. After early reports of therapeutic efficacy, there have been
At D210, following meglumine antimoniate treatment, many reports in recent years of the failure of MLT therapy
the clinical status of dog was greatly improved with resolution and the resistance to therapy with miltefosine against both
of the dry, exfoliative dermatitis and of the alopecia (clinical visceral leishmaniasis (VL) and cutaneous leishmaniasis (CL)
score 5/86) and improvements in the clinicopathological on the Indian subcontinent and new world [14–17, 22, 23].
abnormalities. Studies of in vitro susceptibility of Leishmania infantum
At D270 (from the start of therapy with MA), hair isolated from cases in both people and dogs [24] highlight
regrowth was almost complete and at D450 the dog was the possibility of cross-resistance to the drugs, including MLF,
asymptomatic and the only clinicopathological abnormality used in man for the treatment of leishmaniosis.
was hypergammaglobulinemia and IFAT title at 1 : 80. Clinical disease occurs in patients with a poor cell-
mediated immune response. It is well known that the dog is
a more sensitive host for L. infantum infection than human
patients, but the therapeutic protocol used in the dog of MLT
3. Discussion 2 mg/Kg/for 28 days is similar to that used for human beings
(2.5 mg/Kg/for 28 days) [19]. In a study of 28 dogs treated with
We report the failure of therapeutic response in two dogs one cycle of 28 days with MLF and allopurinol, Pandey et al.
with CanL, following a second cycle of treatment with MFT [11] report that 4 dogs had a relapse and needed a second cycle
in combination with allopurinol, which both responded of therapy which still failed to eradicate the parasite from
promptly to a third therapeutic cycle using another leish- lymph nodes.
manicidal drug. In dogs, there is virtually no treatment that will com-
These reports draw attention to the need for close moni- pletely eliminate parasites from the host and, even if tempo-
toring of the pharmacological activity of new molecules, such rary clinical remission is achieved, a relapse is to be expected
as MLT, against CanL in order to identify the best treatment in weeks to years after drug withdrawal [5, 8]. In this species,
protocol and monitor development of resistance in dogs. successful treatment is thought to depend, at least in part, on
It is important to emphasize that, although both dogs alterations in the host immune response to the parasite. This
had travelled to areas where leishmaniasis is endemic, after makes it difficult to distinguish whether a lack of treatment
diagnosis they remained in nonendemic areas and were efficacy is attributable to the lack of immune surveillance
treated using deltamethrin collars to prevent sandflies from that allows reactivation of the parasite or a true failure
feeding. It is therefore extremely unlikely that reinfection to respond to therapy. In animal models, T-cell-dependent
could have occurred between therapeutic cycles. immune mechanisms are not essential for miltefosine to be
Several factors may have contributed to the failure of effective, suggesting that this agent may be useful in patients
therapeutic response to MLF in the two cases described: with depressed parasite-specific mediated immunity, such as
these could be related to the parasite, the drug, or the host. sick dogs [12, 23].
It is known that differences in exposure to antigens, drug This clinical report is limited by the fact that it was not
pharmacokinetics, doses, frequency of administrations of the possible to demonstrate the presence of a resistance to the
therapy, and immune response of the host may affect outcome drug, because we were not able to select the strain of Leishma-
[17]. nia present in the two cases before and after treatment cycles.
Following oral administration of MLF, there may have However, after an initial clinical improvement following the
been a lack of, or incomplete, drug intake by the dogs or MLT treatment, both dogs relapsed or were unresponsive to
the incomplete absorption of the molecule from the intestine. the second therapeutic cycle.
Underdosing, due to poor owner compliance, is also a Similar to findings in human medicine [19], it can be
possibility and this is less likely to occur with a parenterally assumed that the cycle of therapy was insufficiently long
administered drug (such as salts of antimony) used for the to prevent the resumption of parasite replication and the
third therapeutic cycle [4]. activation of parasite-specific cell-mediated immunity in the
Dorlo et al. [18] established the first evidence for a host. It is also possible that the first cycle of MLF selected
drug exposure-effect relationship in human patients. When a resistant strain of Leishmania which was sensitive to the
treating VL, it is essential to achieve sufficient miltefos- salts of antimony. Certainly, the therapeutic response to MLT
ine exposure for treatment success. In man, it has been was insufficient, whilst the two subjects responded readily
recently reported that the cure rate of mucosal leishmaniasis to another molecule remaining disease-free for 420 and 270
is about 71% after 4 weeks of treatment with miltefosine days, respectively.
(2.5 mg/kg/day) and the duration of therapy was increased in The importance of assessing whether treatment with
this study to try to increase the cure rate [19]. miltefosine in dogs can lead to the selection of drug-resistant
Development of resistance is one of the major concerns Leishmania strains has already been reported [3] and this is
with the wide use of miltefosine [20], and one of the particularly relevant because of the sharing of drugs between
important factors contributing to drug resistance is the human and canine medicine [23]. Therefore, in view of the
use of subtherapeutic doses and/or insufficient duration of relatively low number of antileishmanial drugs available and
therapy [14, 20]. Furthermore, miltefosine has a long half-life the fact that some of these are used in human as well as in
 1792, 2014, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2014/640151 by UECE - Universidade Estadual do Ceara, Wiley Online Library on [02/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
6 Case Reports in Veterinary Medicine

veterinary medicine, vigilance of the clinical efficacy of MIL miltefosine treatment,” American Journal of Tropical Medicine
in dogs is crucial. Clinicians should be encouraged to try to and Hygiene, vol. 75, no. 6, pp. 1074–1077, 2006.
isolate parasites collected from unresponsive dogs and submit [13] V. N. R. Das, K. Pandey, N. Verma et al., “Short report:
these to a suitable laboratory so that the possible onset of drug development of post-kala-azar dermal leishmaniasis (PKDL)
resistance can be monitored. in miltefosine-treated visceral leishmaniasis,” The American
Journal of Tropical Medicine and Hygiene, vol. 80, no. 3, pp. 336–
338, 2009.
Conflict of Interests [14] L. Manna, F. Vitale, S. Reale et al., “Study of efficacy of milte-
None of the authors (Daniela Proverbio, Eva Spada, Giada fosine and allopurinol in dogs with leishmaniosis,” Veterinary
Journal, vol. 182, no. 3, pp. 441–445, 2009.
Bagnagatti De Giorgi, and Roberta Perego) declared any
conflict of interests. [15] M. Mateo, L. Maynard, C. Vischer, P. Bianciardi, and G. Miró,
“Comparative study on the short term efficacy and adverse
effects of miltefosine and meglumine antimoniate in dogs with
Acknowledgment natural leishmaniosis,” Parasitology Research, vol. 105, no. 1, pp.
155–162, 2009.
This research received no specific grant from any funding [16] H. M. Andrade, V. P. C. P. Toledo, M. B. Pinheiro et al.,
agency in the public, commercial, or nonprofit sectors. “Evaluation of miltefosine for the treatment of dogs naturally
infected with L. infantum (=L. chagasi) in Brazil,” Veterinary
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