Treatment failure to intralesional sodium stibogluconate (IL-SSG) is a health challenge for cutaneous leishmaniasis (CL) in Sri Lanka. A randomized controlled proof of principle clinical trial, with two arms (viz., radio frequency–induced heat therapy [RFHT] by a ThermoMed™ device and thermotherapy by a handheld exothermic crystallization thermotherapy for CL [HECT-CL] device) was conducted on 40 CL treatment failures to IL-SSG, from three hospitals in Tangalle, Hambantota, and Anuradhapura, from January 2017 to January 2018, followed up for 180 days post-thermotherapy with a final follow-up in February 2020. Intention-to-treat cure rates were calculated at day 90 (initial cure rate) and at day 180 (final cure rate) posttreatment. Radio frequency–induced heat therapy group: the initial cure rate was 100% (20/20) and the final cure rate was 95% (19/20), with one patient relapsing. The HECT-CL group: both the initial and final cure rates were 80% (16/20), with no relapses and one excluded from the trial. In February 2020 (1.6–3 years posttreatment), 27 traceable patients (RFHT = 16, HECT-CL = 11) remained healed. Second-degree burns were observed with RFHT in 65% (13/20), with HECT-CL in 15% (3/20), which completely resolved subsequently. The cure rates between the two treatment groups were comparable (P = 0.15). Radio frequency–induced heat therapy consumed less time and required only a single hospital visit. Handheld exothermic crystallization thermotherapy for CL is potentially usable at community settings with both being less costly than IL-SSG. This study is the first proof that thermotherapy is an efficacious and safe treatment for CL patients in Sri Lanka, complicated by treatment failure to IL-SSG.

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The first-line treatment for Leishmania donovani-induced cutaneous leishmaniasis (CL) in Sri Lanka is intra-lesional sodium stibogluconate (IL-SSG). Antimony failures in leishmaniasis is a challenge both at regional and global level, threatening the ongoing disease control efforts. There is a dearth of information on treatment failures to routine therapy in Sri Lanka, which hinders policy changes in therapeutics. Laboratory-confirmed CL patients (n = 201) who attended the District General Hospital Hambantota and Base Hospital Tangalle in southern Sri Lanka between 2016 and 2018 were included in a descriptive cohort study and followed up for three months to assess the treatment response of their lesions to IL-SSG. Treatment failure (TF) of total study population was 75.1% and the majority of them were >20 years (127/151,84%). Highest TF was seen in lesions on the trunk (16/18, 89%) while those on head and neck showed the least (31/44, 70%). Nodules were least responsive to therapy (27/31, 87.1%) unlike papules (28/44, 63.6%). Susceptibility to antimony therapy seemed age-dependant with treatment failure associated with factors such as time elapsed since onset to seeking treatment, number and site of the lesions. This is the first detailed study on characteristics of CL treatment failures in Sri Lanka. The findings highlight the need for in depth investigations on pathogenesis of TF and importance of reviewing existing treatment protocols to introduce more effective strategies. Such interventions would enable containment of the rapid spread of L.donovani infections in Sri Lanka that threatens the ongoing regional elimination drive.

SUMMARYThe ability of Sphaerotheca humuli to overwinter as cleistocarps in infected hop cones and leaves and in aerial buds on rootstocks was examined during the winters of 1970‐1, 1971‐2 and 1972‐3.Periodical examination of cleistocarps, collected in October and overwintered in Terylene bags on the soil of a hop garden, consistently revealed two periods of maturation ending in November and in March, when over 50% contained eight, well‐defined ascospores. In laboratory tests cleistocarps, kept either in the hop garden or dry at 4, 8 or 18oC during the winter, could not be encouraged to dehisce earlier than April when naturally dehisced cleistocarps were first detected in the field. More ascospores were discharged from cleistocarps, and germination of ascospores in laboratory tests was greater, at 18 than at 4, 8 or 24oC. Colonies of S. humuli arose on leaves of potted plants exposed to overwintered cleistocarps in the hop garden and were observed microscopically to originate from ascospores. However, a Burkard spore trap, operated amidst the cleistocarps in this garden in 1972 and 1973, failed to detect ascospores. Ascospores, discharged onto susceptible leaves in the laboratory, germinated but failed to produce colonies.It was demonstrated that S. humuli can perennate in aerial, dormant buds on hop rootstocks. Examination of buds in autumn revealed mycelium external to and between the bud scales. At budburst the mycelium was still present internally. Cleistocarps were occasionally associated with hibernating mycelium. Primarily infected shoots arose from plants bearing infected buds in conditions which precluded chance infection. Some evidence was obtained that conditions during the winter determine the success of survival in buds.The fungus appeared to be incapable of infecting a selection of weeds common to hop gardens and their vicinity.