Rhabdomyolysis associated with pentamidine isethionate therapy for American cutaneous leishmaniasis

Sir, In the case of American cutaneous leishmaniasis, the risk of serious morbidity from cutaneous and mucocutaneous forms requires highly effective parenteral therapy. Pentavalent antimony compounds have been the mainstay of antileish-manial therapy for half a century. However, despite high effectiveness, these drugs require long duration regimens and cause frequent and serious toxic effects. Short courses of pentamidine isethionate therapy have been shown to be highly effective and acceptably tolerated as an alternative to antimony in the treatment of Viannia subgenus American cutaneous leishmaniasis. 1 In French Guiana, where Leishmania [V] guyanensis is predominant, pentamidine mesylate was first used with different regimens from 1980 to 1992 at Cayenne hospital. Since 1992, short courses of pentamidine isethionate have been used successfully as a first-line therapy for cutaneous leish-maniasis. Since late 2000, the effectiveness and safety of an intramuscularly administered single-dose therapy of 7 mg/kg of pentamidine isethionate have been evaluated as a standard outpatient treatment for cutaneous leishmaniasis at Cayenne hospital. Rhabdomyolysis appears to be an extremely frequent adverse effect of pentamidine isethionate. A total of 45 patients with cutaneous leishmaniasis were seen between November 2001 and May 2002 at Cayenne hospital. They received a single intramuscular dose of 7 mg/kg of pentamidine isethionate (Pentacarinat; Aventis). Venous cre-atine kinase (CK) level was assessed at days 2 and 15 after the injection. At 2 months follow-up, patients were asked what adverse effects of treatment there had been. Early CK levels were measured for 26 out of 45 patients, showing substantially increased CK levels (>1000 U/L) in 19 (73%) patients (range 1032–9312 U/L, median 3096 U/L). Early CK levels were normal (<165 U/L) in three (11.5%) patients, and slightly increased (>165 and <1000 U/L) in four (15.5%) patients. When assessed in the high CK level cases, urea and creatinine levels did not reveal any renal failure related to rhabdomyolysis. Potassium and calcium levels were within normal limits as well. Late CK levels were measured for 18 out of 45 patients, and CK levels had normalized in 12 patients and were close to the normal range in the other six. At 2 months follow-up, 27 out of 45 patients were seen, including 16 of the 23 patients with increased early CK levels. All patients were asymptomatic. Frequent transitory local pain at the injection site was reported. No other complications had occurred for the patients with pentamidine-induced rhabdomyolysis at this 2 month follow-up. Most of …