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TSP in Ecuador
342 TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE (1995) 89, CORRESPONDENCE
( Correspondence
1
Albendazole and ivermectin treatment of strongyloidiasis We were interested in the paper by Dr Datry and colleagues comparing the therapeutic efficacies of ivermectin and albendazole for patients with strongyloidiasis (1994: Transactions, 88, 344). We hope that the excellent results they obtained with ivermectin will be confirmed by further studies, particularly as ivermectin appears to be effective in treating disseminated strongyloidiasis in HIV-infected patients (Torres et al., 1994: Clinical Znfectious Diseases, 17,900). We were concerned by the apparent lack of efficacy of albendazole therapy, which differs from our own experience and that of the previous studies cited in their naner. We sneculate that the dose of albendazole (400 mg daily for f d) used in their study was too small, but the authors did not supply details about the weight, age, geographical origin or chronicity of infection of the patients they treated. In our own review of 47 older patients (mean age 70 years) with chronic strongyloidiasis treated with 400 mg albendazole twice daily for 3 d, 75% were cured at 6 months’ follow-up. A further 37% of the treatment failure group responded to a second cycle of treatment of the samedose and duration (Archibald et al., 1993: QuarterlyJournal ofMedicine, 86,191). The anthehnintic effects of albendazole are probably related to inhibition of parasite tubulin and are likely to be parasitostatic rather than parasitocidal. Adequate doses need to be given for at least 3 d to produce sustained cure rates of Ascaris lumbricoides and Trichuris trichiuru infections of children (Hall & Nagar? 1994: Trunsuctions, 88, llO), and we speculate that this also applies to infections with Strongyloides spp. We believe that a prospective study of the treatment of uncomplicated strongyloidiasis should compare single or repeated doses of ivermectin with albendazole given in dosesof at least 800 mg per day (for adults) for 3 d, perhaps repeated after a week. Although such regimens of albendazole are more difficult to administer, the drug is readily available in the tropics and has a well-established safety profile. N. J.pyhG$; . . Liverpool School of Tropical Medicine Pembroke Place Liverpool, L3 SQA, UK
23 September 1994
Albendazole and ivermectin treatment of strongyloidiasis: a reply In reply to Dr Beeching’s and Dr Gill’s comments [above] concerning our article on the treatment of strongyloidiasis with ivermectin compared with albendazole in an open study of 60 cases(Datry et al., 1994: Trunsuctions, 88,344), we wish to make the following comments. (i) We agree that a higher dose of albendazole (800 mg daily for 3 d repeated after one week) would be more effective than 400 mg of albendazole daily for 3 d. However, the dose recommended by the Smith Kline and French laboratory for the treatment of strongyloidiasis is 400 mg daily for 3 d . (ii) Both our experimental groups had similar demographic characteristics. In the ivermectin group, mean age was 37 vears (ranee 22-67). mean weight was 65 ke (39-8 1) and the geographical ‘origins of ?he members were sub-Saharan Africa, Caribbean, south-east Asia and Latin America. In the albendazole group, mean age was 36.1 years (14-75), mean weight 65.4 kg (4%90)! and the geographical origins were the same. All the subjects had moderately chronic Strongyloides infection, except for one man in the ivermectin group, who had had chronic persistent strongyloidiasis for 14 years despite 20 periods of
treatment with conventional drugs. He was cured definitively with a double dose of ivermectin (Lyagoubi et al., 1992: Transactions, 86,541). (iii) Finally, we feel that ivermectin is a better treatment for strongyloidiasis because83% of patients treated with a single dose of ivermectin were cured whereas treatment for 3 d is necessaryif albendazole is used. Annick Datry Ingibjiirg Hiarsdottir DEpartement des Maladies Infect&es, taires et de Sante Publique Groupe Hospitalier PitieSalpltriere 47 Boulevard de I’Hopital 75651 Paris Cedex 13 France
Tropicales, Parasi-
2 December 1994
HAWTSP in Ecuador A recent paper by Guderian et al. (1994: Transactions, 88, 399-400) stated that they were reporting the first casesof HTLV-1 associatedmyelopathy/tropical spastic paraparesis (HAM/TSP) from Ecuador. Our group has been studying HAMiTSP for many years, and we have already reported it from Ecuador (Alarcon et al., 1990: Medicina de Hay, 9,48; 1991: VIZZ Panamerican Congress of Neurology, 38; 1992: Revista Ecuatoriana de Neurologia, 1, 54; Leon-S. et al., 1994: Revista Medica de Chile, 122,265). Nine of our 10 HAM/TSP caseswere screened for HTLV-1 infection by ELISA (Organon) and by Western blotting (DuPont). On the other hand, the very low titres of antibodies against HTLV-1 and the very few cases of HAM/TSP found in people with African ancestors living on the Colombian Caribbean coast (Boshell et al., 1994: AIDS Research and Human Retroviruses, 10,487) together with the frequent presence of HTLV-1 in natives of South America (Miura et al., 1994, cited by Leon-S. et al., in press: South Pacific Study), do not totally support the suggestion by Guderian et al. (lot. cit.) of the arrival of this retrovirus on the Pacific coast of South America from Africa. Zaninovic et al. (1990: Nature, 344, 299) commented that HTLV-1 could have come to South America from Asia through the Bering strait, and we reported that the south-west of Colombia and the northwest of Ecuador have many ancient cultural, anthropological, archeological, genetic and virological similarities which they also share with the Japanese people, especially those living around Kyushu island (Leon-S. et al., lot. cit.). These facts suggest that HTLV-1 and its carriers probably could have come directly from the Japaneseregion to South America, following the Pacific seacurrents which unite these regions, at least 6000 years ago (Leon-S. et al., lot. cit.). The haplotype similarities in the populations of those areas support our suggestion (Sonoda et al., 1994, cited by Leon-S. et al., lot. cit.). Finally, the fact that similar social, nutritional, hy ienic, and economic conditions, etc., annlv to HAM/T 8P natients from both Colombia and Ecuador, strongly suggeststhat environmental cofactors play a role in inducing overt diseasein those genetically predisposed to disease manifestation (Leon-S. & Zaninovic, in press: Actu Medica Colombiana). We thank Dr Gustav0 Roman for doing the Western blot studies, and Dr Amparo Ariza-Deleon for help with the English.
Fidias E. Leon-S. Ryugakusei International Exchange Programme Tagami 7 chome 19-l 7, IZagoshima,Japan (Present address: Conjunto Residential Villa de 10s Conquistadores, Casa 49, Bucaramanga, Colombia, South America)
Tomas A. Alarcon Unit of Neurology, Teodoro Maldonado Hospital, Guayaquil, Ecuador 7 October 1994
( Correspondence
1
Albendazole and ivermectin treatment of strongyloidiasis We were interested in the paper by Dr Datry and colleagues comparing the therapeutic efficacies of ivermectin and albendazole for patients with strongyloidiasis (1994: Transactions, 88, 344). We hope that the excellent results they obtained with ivermectin will be confirmed by further studies, particularly as ivermectin appears to be effective in treating disseminated strongyloidiasis in HIV-infected patients (Torres et al., 1994: Clinical Znfectious Diseases, 17,900). We were concerned by the apparent lack of efficacy of albendazole therapy, which differs from our own experience and that of the previous studies cited in their naner. We sneculate that the dose of albendazole (400 mg daily for f d) used in their study was too small, but the authors did not supply details about the weight, age, geographical origin or chronicity of infection of the patients they treated. In our own review of 47 older patients (mean age 70 years) with chronic strongyloidiasis treated with 400 mg albendazole twice daily for 3 d, 75% were cured at 6 months’ follow-up. A further 37% of the treatment failure group responded to a second cycle of treatment of the samedose and duration (Archibald et al., 1993: QuarterlyJournal ofMedicine, 86,191). The anthehnintic effects of albendazole are probably related to inhibition of parasite tubulin and are likely to be parasitostatic rather than parasitocidal. Adequate doses need to be given for at least 3 d to produce sustained cure rates of Ascaris lumbricoides and Trichuris trichiuru infections of children (Hall & Nagar? 1994: Trunsuctions, 88, llO), and we speculate that this also applies to infections with Strongyloides spp. We believe that a prospective study of the treatment of uncomplicated strongyloidiasis should compare single or repeated doses of ivermectin with albendazole given in dosesof at least 800 mg per day (for adults) for 3 d, perhaps repeated after a week. Although such regimens of albendazole are more difficult to administer, the drug is readily available in the tropics and has a well-established safety profile. N. J.pyhG$; . . Liverpool School of Tropical Medicine Pembroke Place Liverpool, L3 SQA, UK
23 September 1994
Albendazole and ivermectin treatment of strongyloidiasis: a reply In reply to Dr Beeching’s and Dr Gill’s comments [above] concerning our article on the treatment of strongyloidiasis with ivermectin compared with albendazole in an open study of 60 cases(Datry et al., 1994: Trunsuctions, 88,344), we wish to make the following comments. (i) We agree that a higher dose of albendazole (800 mg daily for 3 d repeated after one week) would be more effective than 400 mg of albendazole daily for 3 d. However, the dose recommended by the Smith Kline and French laboratory for the treatment of strongyloidiasis is 400 mg daily for 3 d . (ii) Both our experimental groups had similar demographic characteristics. In the ivermectin group, mean age was 37 vears (ranee 22-67). mean weight was 65 ke (39-8 1) and the geographical ‘origins of ?he members were sub-Saharan Africa, Caribbean, south-east Asia and Latin America. In the albendazole group, mean age was 36.1 years (14-75), mean weight 65.4 kg (4%90)! and the geographical origins were the same. All the subjects had moderately chronic Strongyloides infection, except for one man in the ivermectin group, who had had chronic persistent strongyloidiasis for 14 years despite 20 periods of
treatment with conventional drugs. He was cured definitively with a double dose of ivermectin (Lyagoubi et al., 1992: Transactions, 86,541). (iii) Finally, we feel that ivermectin is a better treatment for strongyloidiasis because83% of patients treated with a single dose of ivermectin were cured whereas treatment for 3 d is necessaryif albendazole is used. Annick Datry Ingibjiirg Hiarsdottir DEpartement des Maladies Infect&es, taires et de Sante Publique Groupe Hospitalier PitieSalpltriere 47 Boulevard de I’Hopital 75651 Paris Cedex 13 France
Tropicales, Parasi-
2 December 1994
HAWTSP in Ecuador A recent paper by Guderian et al. (1994: Transactions, 88, 399-400) stated that they were reporting the first casesof HTLV-1 associatedmyelopathy/tropical spastic paraparesis (HAM/TSP) from Ecuador. Our group has been studying HAMiTSP for many years, and we have already reported it from Ecuador (Alarcon et al., 1990: Medicina de Hay, 9,48; 1991: VIZZ Panamerican Congress of Neurology, 38; 1992: Revista Ecuatoriana de Neurologia, 1, 54; Leon-S. et al., 1994: Revista Medica de Chile, 122,265). Nine of our 10 HAM/TSP caseswere screened for HTLV-1 infection by ELISA (Organon) and by Western blotting (DuPont). On the other hand, the very low titres of antibodies against HTLV-1 and the very few cases of HAM/TSP found in people with African ancestors living on the Colombian Caribbean coast (Boshell et al., 1994: AIDS Research and Human Retroviruses, 10,487) together with the frequent presence of HTLV-1 in natives of South America (Miura et al., 1994, cited by Leon-S. et al., in press: South Pacific Study), do not totally support the suggestion by Guderian et al. (lot. cit.) of the arrival of this retrovirus on the Pacific coast of South America from Africa. Zaninovic et al. (1990: Nature, 344, 299) commented that HTLV-1 could have come to South America from Asia through the Bering strait, and we reported that the south-west of Colombia and the northwest of Ecuador have many ancient cultural, anthropological, archeological, genetic and virological similarities which they also share with the Japanese people, especially those living around Kyushu island (Leon-S. et al., lot. cit.). These facts suggest that HTLV-1 and its carriers probably could have come directly from the Japaneseregion to South America, following the Pacific seacurrents which unite these regions, at least 6000 years ago (Leon-S. et al., lot. cit.). The haplotype similarities in the populations of those areas support our suggestion (Sonoda et al., 1994, cited by Leon-S. et al., lot. cit.). Finally, the fact that similar social, nutritional, hy ienic, and economic conditions, etc., annlv to HAM/T 8P natients from both Colombia and Ecuador, strongly suggeststhat environmental cofactors play a role in inducing overt diseasein those genetically predisposed to disease manifestation (Leon-S. & Zaninovic, in press: Actu Medica Colombiana). We thank Dr Gustav0 Roman for doing the Western blot studies, and Dr Amparo Ariza-Deleon for help with the English.
Fidias E. Leon-S. Ryugakusei International Exchange Programme Tagami 7 chome 19-l 7, IZagoshima,Japan (Present address: Conjunto Residential Villa de 10s Conquistadores, Casa 49, Bucaramanga, Colombia, South America)
Tomas A. Alarcon Unit of Neurology, Teodoro Maldonado Hospital, Guayaquil, Ecuador 7 October 1994