Original Article
Cellular infiltrate in cutaneous leishmaniasis lesions and therapeutic outcome
Camila Sampaio Ribeiroa, Riam Rocha Françab, Juliana Almeida Silvaa, Silvana Conceição da Silvaa, Sílvia R.B. Ulianac, Viviane Sampaio Boaventuraa,b, Paulo R.L. Machadoa,
Autor para correspondência
a Immunology Service, Hospital Universitário Prof. Edgar Santos, Universidade Federal da Bahia, Salvador, BA, Brazil
b Research Center, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, BA, Brazil
c Leishmaniasis Laboratory, Department of Parasitology, Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo, SP, Brazil
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"apellidos" => "Machado" "email" => array:1 [ 0 => "dracamiladermato@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Immunology Service, Hospital Universitário Prof. Edgar Santos, Universidade Federal da Bahia, Salvador, BA, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Research Center, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, BA, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Leishmaniasis Laboratory, Department of Parasitology, Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo, SP, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 856 "Ancho" => 905 "Tamanyo" => 232757 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Plasma cells (red arrows) in the dermis of a fragment of skin biopsy of a CL ulcer (×400).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cutaneous Leishmaniasis (CL) is caused by an intracellular protozoan of the genus Leishmania transmitted to humans by inoculation through a mosquito bite. CL is endemic in South America and Brazil is amongst the ten countries that concentrate 75% of the cases of CL worldwide.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is typically a low-income country disease associated with poverty and unsanitary conditions.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">CL has a complex immunopathogenesis that has not been fully understood. It is well established that, in general, the main defense mechanism against intracellular agents, such as Leishmania, is associated with activation of cellular immunity through the production of Th1 cytokines such as IFN-γ, TNF-α and IL-12.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In contrast, humoral immunity-related to Th2 cell response is associated with the persistence of intracellular organisms and thus, the progression of the infection.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Therefore, Th1 immunity response would be adequate and effective to destroy parasites and avoid disease or promote a clinical cure. However, several data indicate that an exaggerated and unbalanced Th1 response may lead to intense tissue damage and more severe clinical forms of the disease.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> In fact, it has been demonstrated that the ulcer size was positively correlated with circulating Th1 cytokines (IFN-γ and TNF-α) and activated T cells, which corroborates with this assumption.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Additionally, it has been demonstrated an in-situ predominance of Th1 inflammatory cytokines (IFN-γ and IL-12) than anti-inflammatory ones (IL-10 and IL-4) before treatment of CL as well as a significant reduction of circulating TNF-α and IFN-γ levels after therapy and healing.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,8</span></a> It has also been shown an association between cells expressing IL-17 and the intensity of the inflammatory infiltration.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">It is evident the important role of the immune system in the pathogenesis of CL and its implications for a definitive cure. Consequently, understanding the evolving local inflammatory response and its correlation to the healing of CL through characterization of the immune pattern at the lesion site may function as a therapeutic outcome predictor. The objective of this study was to verify if the cellular composition of the inflammatory infiltrates as well as CD4, CD8 and IL-17 expression at lesion site may correlate with therapeutic outcome in CL, a data not yet explored in the literature.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Population studied and follow-up</span><p id="par0025" class="elsevierStylePara elsevierViewall">Patients were referred to the health post of Corte de Pedra, Bahia, Brazil, an endemic area of <span class="elsevierStyleItalic">Leishmania braziliensis</span> transmission. Patients included had an age of 18–65 years; diagnosis of CL between 30 and 90 days from the beginning of the cutaneous lesion; 01–05 ulcers with diameter, on its longest axis, between 10–50 mm. The diagnosis was confirmed through either histopathological examination showing amastigotes or by positive PCR for <span class="elsevierStyleItalic">L. braziliensis</span>. The exclusion criteria were pregnancy or breastfeeding, other associated acute or chronic illness, and previous leishmaniasis. Patients who met the entry criteria were randomly allocated to 3 groups: parental Glucantime® (Sb<span class="elsevierStyleSup">V</span>) plus oral tamoxifen (OT), Sb<span class="elsevierStyleSup">V</span> plus topic tamoxifen (TT) or Sb<span class="elsevierStyleSup">V</span> only (control group). Patients were followed up monthly during 6 months to define therapeutic outcome; the details of the trial are described elsewhere.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Ethical aspects</span><p id="par0030" class="elsevierStylePara elsevierViewall">The study was approved by the Ethics Committee of the Hospital Universitário Professor Edgard Santos in Bahia-Brazil (Research protocol nº 106/2009) and by the Ethics Committee of the University of São Paulo (Research protocol nº 993.562). Written informed consent was obtained from all patients included in the study.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Drug administration</span><p id="par0035" class="elsevierStylePara elsevierViewall">Meglumine antimoniate (Glucantime®, Aventis) was administered intravenously at a dose of 20 mg Sb<span class="elsevierStyleSup">V</span>/kg/day for 20 days; oral tamoxifen (Sandoz) at a dosage of 20 mg twice a day during 20 days; tamoxifen 0.1% cream (compound drug) applied over all ulcers twice a day during 20 days (without dressing).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Efficacy assessment</span><p id="par0040" class="elsevierStylePara elsevierViewall">The initial and definite cure was defined as complete cicatrization of the lesion(s) without any infiltration in the borders, 2 and 6 months after the end of treatment, respectively.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Biopsy and histopathology</span><p id="par0045" class="elsevierStylePara elsevierViewall">A 4-mm punch biopsy was performed from the borders of the ulcers under local anesthesia prior to therapy. Fragments were fixed in a 10% formalin solution. Skin biopsies samples underwent routine histological processing and slides were stained with Hematoxylin and Eosin (H&E) for histopathological evaluation (inflammation pattern – perivascular or nodular and diffuse – the presence of necrosis, and cellular infiltrate composition: neutrophils, plasma cells, lymphocytes, eosinophils, histiocytes, epithelioid cells, giant cells, as well as the presence of amastigotes).</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Immunohistochemistry</span><p id="par0050" class="elsevierStylePara elsevierViewall">An immunohistochemical study was performed as previously described on 33 biopsies.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The following primary antibodies were used: rabbit anti-IL-17 (Santa Cruz Biotechnology, Santa Cruz, CA, USA) and mouse anti-CD8 (Dako, Carpinteria, California, USA), mouse anti-CD4 (Dako, Carpinteria, California, USA). Biotin-labeled anti-rabbit, anti-mouse IgG (DAKO HRP Advance – K 4068) was used as a secondary antibody. Digital images from all immunohistochemical-stained sections were acquired using an optical microscope (Nikon E-600) coupled to a digital Q-color 1 camera Olympus at 400× magnification. The expression levels of TCD4, TCD8 and IL-17 at the infiltrate were analyzed in five continuous fields per fragment and quantified by measurement of the area of stained cells/total area in the field. The first field selected for quantification on each specimen was the one containing visually more immunostained cells. Quantification of stained areas was performed blindly by two independent readers (CSR and VB) using Image-Pro Plus software (Media Cybernetics) and the result was expressed as median (quartile 25 to quartile 75). The results were correlated with these variables: area of the lesion, area of the lymphadenopathy, duration of the disease at day 0, and therapeutic outcome at 6 months.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Statistical analyses. Statistical analyses were performed using SPSS® version 20 for MAC® and also Prism 4 (GraphPad Software, San Diego, CA, USA). Differences were considered significant when p < 0.05. Continuous variables were expressed as median and the difference between the three groups was calculated by the Kruskal-Wallis Test and between two groups by the Mann-Whitney Test. Categorical variables were expressed as absolute frequency and relative frequency and to calculate the difference between three groups the Chi-Square Test was used and between two groups the Exact Fisher Test was performed. Cure rates were calculate using both Intention-To-Treat (ITT) and Per Protocol (PP) analysis.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Therapeutic outcomes</span><p id="par0060" class="elsevierStylePara elsevierViewall">The 38 CL patients were allocated into three groups: Sb<span class="elsevierStyleSup">V</span> (n = 15); Sb<span class="elsevierStyleSup">V</span>+TT (n = 11) and Sb<span class="elsevierStyleSup">V</span>+OT (n = 12) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). During follow-up, 04 patients did not complete correctly the treatment protocol due to: adverse reaction (02 patients: one from the Sb<span class="elsevierStyleSup">V</span>+TT group and the other from the Sb<span class="elsevierStyleSup">V</span>+OT group), use of Sb<span class="elsevierStyleSup">V</span> subdose (01 patient from Sb<span class="elsevierStyleSup">V</span>+OT group), and 01 patient from the control group did not return to medical evaluations after inclusion. These patients were excluded from this in situ study. In addition, one patient of the clinical trial was not submitted to skin biopsy and was also excluded from this analysis. Thereby, among 38 patients of the clinical trial, 33 were part of this in situ study. Although not significant, the highest cure rates of 80% and 70%, were observed in the group Sb<span class="elsevierStyleSup">V</span>+OT, at 2 and 6 months respectively (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Immunological markers</span><p id="par0065" class="elsevierStylePara elsevierViewall">The expression of CD8<span class="elsevierStyleSup">+</span> T in CL lesions before treatment is showed in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. The analysis of the mean percentage of positively immunostained CD4<span class="elsevierStyleSup">+</span> T and CD8<span class="elsevierStyleSup">+</span> T-cells (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) showed a higher expression of CD8<span class="elsevierStyleSup">+</span> T-cells. For both subpopulations, there were no differences in their expression between patients who healed (n = 17) and those who presented failure (n = 16) at 2 months. IL-17 immunostaining was higher in the failure group, however, there was no significant difference between cure and failure groups (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In addition, the evaluation of the expression of IL-17, CD4<span class="elsevierStyleSup">+</span>T and CD8<span class="elsevierStyleSup">+</span> T-cells showed no differences when the authors compared the treatment subgroups (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Histopathological aspects</span><p id="par0070" class="elsevierStylePara elsevierViewall">The evaluation of the inflammatory infiltrates showed few differences among the cases. Most patients had biopsies with nodular and diffuse inflammation patterns and only 02 patients presented a superficial and deep perivascular pattern. In all cases, the predominant inflammatory cells were macrophages and lymphocytes. The majority had neutrophils 26/33 (78%) and in 14/33 cases (42%), areas of necrosis were observed in the dermis. Giant cells were visualized in 13/33 (39%) of lesions. In 3 out of 33 fragments analyzed, a significant amount of eosinophils was observed. Plasma cells were found in inflammatory infiltrate of the majority of CL patients (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). Interestingly, plasma cells were absent in 11 out of 33 subjects (33%), and all those 11 patients were cured at 2 months, with only one relapse before 6 months (p < 0.05) (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Pathogenesis of CL follows a complex set of interactions between many factors triggered by the host’s innate and acquired immune responses. These inflammatory responses mediate infection outcome and disease expression.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The role of CD8<span class="elsevierStyleSup">+</span> T-cells in Leishmania infection may be associated with protection or tissue damage depending upon the effector functions triggered by the infection.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> However, there has been increasing evidence of the association of CD8<span class="elsevierStyleSup">+</span> T-cells with disease progression and pathology. There is a higher frequency of CD8<span class="elsevierStyleSup">+</span> T-cells in CL ulcers compared to early CL lesions before ulceration; CD8<span class="elsevierStyleSup">+</span> T-cells from ulcerated CL patients produced more granzyme B and had more cytotoxic activity than the cells from patients with subclinical infection; CD8<span class="elsevierStyleSup">+</span> T-cell-mediated cytotoxicity activates the NLRP3 inflammasome in CL lesions.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14–16</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In the present study, the authors observed a predominance of CD8<span class="elsevierStyleSup">+</span> T-cells over CD4<span class="elsevierStyleSup">+</span> T-cells in the pre-treatment ulcerated lesion. This observation strengthens the idea that CD8<span class="elsevierStyleSup">+</span> T-cells are more involved in the pathogenesis of the disease than CD4<span class="elsevierStyleSup">+</span> T-cells. However, we were not able to associate the expression of CD8<span class="elsevierStyleSup">+</span> or CD4<span class="elsevierStyleSup">+</span> T-cells to therapeutic outcomes.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The authors of the present study have also evaluated IL-17 expression due to its direct association with the inflammatory infiltrate on CL and its possible role in pathology.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Although its highest expression was found in a CL subject that failed therapy, the comparison between the groups showed no differences. It is possible that a higher sample size as well as the evaluation of other inflammatory mediators like Il- or granzyme, could contribute to evaluating the CD8<span class="elsevierStyleSup">+</span> T profile present in the lesions and more accurately provide correlation with therapeutic outcome.</p><p id="par0095" class="elsevierStylePara elsevierViewall">A striking data was the correlation between the absence of plasma cells in the ulcer before treatment and therapeutic cure at 2 months in all subjects, although one patient relapsed between 2 and 6 months. The presence of plasma cells is recognized as an important feature of the inflammatory infiltrate in CL. However, the exact role of plasm cells in CL pathogenesis remains to be determined and it has probably been underestimated. Ridley et al. noted a significant positive correlation between the presence of necrosis and intensity of plasma cell and lymphocyte infiltration.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> On the other hand, skin biopsies of non-ulcerated or atypical CL lesions, presumably with a lower inflammatory reaction, presented also a smaller amount of plasma cells.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> In the late stages of the CL lesion, a large number of plasma cells are typically present.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Limitations of the study are the low number of patients and the absence of the evaluation of other markers of immune response in situ.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusion</span><p id="par0100" class="elsevierStylePara elsevierViewall">The present study’s data suggest a possible role for plasma cells in the pathology of CL and as a marker of therapeutic outcome, since their absence in the infiltrate was associated with cure in all cases with only one relapse. Further evaluation of specific markers for B cells and plasmocytes in CL ulcers as well as functional studies should be performed to verify its potential pathogenic role in CL.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Financial support</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleGrantSponsor" id="gs0005">Funaderm</span>– Fundo de Apoio à Dermatologia.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Authors' contributions</span><p id="par0110" class="elsevierStylePara elsevierViewall">Camila Sampaio Ribeiro: Approval of the final version of the manuscript; critical literature review; data collection, analysis, and interpretation; intellectual participation in propaedeutic and/or therapeutic management of studied cases; manuscript critical review; preparation and writing of the manuscript.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Riam Rocha França: Approval of the final version of the manuscript; data collection, analysis, and interpretation; preparation and writing of the manuscript; statistical analysis.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Juliana Almeida Silva: Approval of the final version of the manuscript; data collection, analysis, and interpretation; preparation and writing of the manuscript.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Silvana Conceição da Silva: Approval of the final version of the manuscript; data collection, analysis, and interpretation; preparation and writing of the manuscript.</p><p id="par1130" class="elsevierStylePara elsevierViewall">Sílvia R.B. Uliana: Intellectual participation in propaedeutic and/or therapeutic management of studied cases; data collection, analysis, and interpretation.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Viviane Sampaio Boaventura: Approval of the final version of the manuscript; critical literature review; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic management of studied cases; manuscript critical review; preparation and writing of the manuscript.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Paulo R. L. Machado: Approval of the final version of the manuscript; critical literature review; data collection, analysis, and interpretation; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic management of studied cases; manuscript critical review; preparation and writing of the manuscript; study conception and planning.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1581928" "titulo" => "Abstract" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Study limitations" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1423921" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Population studied and follow-up" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Ethical aspects" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Drug administration" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Efficacy assessment" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Biopsy and histopathology" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Immunohistochemistry" ] ] ] 4 => array:3 [ "identificador" => "sec0045" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Therapeutic outcomes" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Immunological markers" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Histopathological aspects" ] ] ] 5 => array:2 [ "identificador" => "sec0065" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0070" "titulo" => "Conclusion" ] 7 => array:2 [ "identificador" => "sec0075" "titulo" => "Financial support" ] 8 => array:2 [ "identificador" => "sec0080" "titulo" => "Authors' contributions" ] 9 => array:2 [ "identificador" => "sec0085" "titulo" => "Conflicts of interest" ] 10 => array:2 [ "identificador" => "xack558746" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-12-03" "fechaAceptado" => "2021-02-07" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1423921" "palabras" => array:6 [ 0 => "CD4 antigens" 1 => "CD8 antigens" 2 => "Immunohistochemistry" 3 => "Interleukin-17" 4 => "Leishmaniasis, cutaneous" 5 => "Plasma cells" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The treatment of cutaneous leishmaniasis is a challenge. A better understanding of the in situ mechanisms involved in the evolution and cure of the disease is essential for the development of new therapies.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Correlate histopathological and immunological characteristics of cutaneous leishmaniasis lesions with clinical outcome after different treatment regimens.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The authors analyzed cellular infiltration and immunohistochemistry staining for CD4, CD8 and IL-17 in biopsy samples from 33 patients with cutaneous leishmaniasis before treatment. All patients were recruited in a randomized clinical trial at Corte de Pedra (Bahia-Brazil) and assigned to receive Glucantime®, Glucantime® + Oral Tamoxifen or Glucantime® + Topical Tamoxifen. Patients were followed for 2 to 6 months to define disease outcome.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A similar expression of CD4, CD8 and IL-17 was observed in lesion samples regardless of clinical outcome. In general, a higher amount of CD8 cells were observed compared with CD4 cells. An important observation was that all patients whose cellular infiltrate did not contain plasma cells were cured after treatment.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Study limitations</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Isolated quantification of TCD8 and IL-17 using immunohistochemistry is insufficient to analyze the role of these molecules in the immunopathogenesis of cutaneous leishmaniasis. In addition, the expansion of the immunohistochemistry panel would allow a more complete analysis of the immune response in situ.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusions</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The absence of plasma cells in cutaneous leishmaniasis lesions was related to a favorable therapeutic outcome.</p></span>" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Study limitations" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusions" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">How to cite this article: Ribeiro CS, França RR, Silva JA, Silva SC, Uliana SRB, Boaventura VS, Machado PRL. Cellular infiltrate in cutaneous leishmaniasis lesions and therapeutic outcome. An Bras Dermatol. 2021;96:544–50.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Study conducted at the Immunology Service. Hospital Universitário Prof. Edgar Santos. Universidade Federal da Bahia, Universidade Federal da Bahia, Salvador, BA, Brazil.</p>" ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 859 "Ancho" => 905 "Tamanyo" => 187075 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Skin fragment of CL ulcer showing immunohistochemical reaction evidencing CD8<span class="elsevierStyleSup">+</span> T-cells (×400).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2479 "Ancho" => 2925 "Tamanyo" => 145946 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A), CD4<span class="elsevierStyleSup">+</span> T; (B), CD8<span class="elsevierStyleSup">+</span> T; (C), IL-17 expression in healed and persistent lesions 2 months after treatment.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2450 "Ancho" => 2917 "Tamanyo" => 300453 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Percentage of the marked area of (A), CD4<span class="elsevierStyleSup">+</span> T; (B), IL-17; (C) CD8<span class="elsevierStyleSup">+</span> T in patients who healed and those who failed 2 months after the end of the treatment separated by treatment group.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 856 "Ancho" => 905 "Tamanyo" => 232757 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Plasma cells (red arrows) in the dermis of a fragment of skin biopsy of a CL ulcer (×400).</p>" ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 863 "Ancho" => 1508 "Tamanyo" => 115233 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Plasma cells and therapeutic outcome 6 months after the end of the treatment in CL patients. <span class="elsevierStyleBold">*</span> p < 0.05 (Fisher’s exact test).</p>" ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Sb<span class="elsevierStyleSup">V</span> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Sb<span class="elsevierStyleSup">V</span> + TT \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Sb<span class="elsevierStyleSup">V</span> + TO \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">p-value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">(n = 14) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">(n = 10) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">(n = 10) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Cure rate at 2 months</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (57%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (50%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (80%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ns<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Cure rate at 6 months</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (43%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (40%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (70%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ns<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2709809.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Pearsons Chi-Square test (comparison between all three groups and also between groups in pair); ns, not statistically significant.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Therapeutic outcome 2 months and 6 months after the end of the treatment by treatment group.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Leishmaniasis worldwide and global estimates of its incidence" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. 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| 2023 Janeiro | 45 | 50 | 95 |
| 2022 Dezembro | 89 | 41 | 130 |
| 2022 Novembro | 78 | 76 | 154 |
| 2022 Outubro | 108 | 61 | 169 |
| 2022 Setembro | 70 | 72 | 142 |
| 2022 Agosto | 46 | 56 | 102 |
| 2022 Julho | 47 | 66 | 113 |
| 2022 Junho | 48 | 61 | 109 |
| 2022 Maio | 54 | 50 | 104 |
| 2022 Abril | 83 | 50 | 133 |
| 2022 Março | 59 | 76 | 135 |
| 2022 Fevereiro | 47 | 39 | 86 |
| 2022 Janeiro | 75 | 96 | 171 |
| 2021 Dezembro | 79 | 70 | 149 |
| 2021 Novembro | 72 | 63 | 135 |
| 2021 Outubro | 100 | 96 | 196 |
| 2021 Setembro | 170 | 107 | 277 |
| 2021 Agosto | 58 | 69 | 127 |
| 2021 Julho | 3 | 3 | 6 |
Mostrar tudo
