TY - JOUR
KW - Leishmaniasis
KW - Parasitic Diseases
KW - Leishmania
KW - Leishmania infantum
KW - Asia
KW - Thailand
KW - Amphotericin B
KW - Therapeutic challenges
AU - Lerona PGE
AU - Jitmuang A
AU - Sarasombath PT
AU - Chayakulkeeree M
AU - Kumlert R
AU - Siriyasatien P
AU - Darby AC
AU - Preativatanyou K
AU - Singh S
AB - <jats:p>
                    Miltefosine, the only oral antileishmanial drug with regulatory approval, has expanded treatment options in several endemic settings but shows variable efficacy across
                    <jats:italic>Leishmania</jats:italic>
                    species, clinical forms, and host immune contexts. In Southeast Asia, where
                    <jats:italic>Leishmania</jats:italic>
                    (
                    <jats:italic>Mundinia</jats:italic>
                    )
                    <jats:italic>martiniquensis</jats:italic>
                    and
                    <jats:italic>L.</jats:italic>
                    (
                    <jats:italic>M.</jats:italic>
                    )
                    <jats:italic>orientalis</jats:italic>
                     are increasingly reported, amphotericin B formulations remain the main treatment despite toxicity, relapse, and implementation constraints. This review evaluates miltefosine’s clinical relevance, mechanisms of action, and resistance pathways, with emphasis on Thailand and neighboring Southeast Asian settings. A Thai compassionate-use case using miltefosine with liposomal amphotericin B for refractory
                    <jats:italic>L. martiniquensis</jats:italic>
                    infection achieved repeated clinical improvement and culture negativity after combination induction, although monotherapy was insufficient to maintain remission in advanced immunosuppression. Evidence from other endemic regions indicates that poor adherence, unregulated access, prolonged subtherapeutic exposure, and inadequate monitoring can reduce treatment durability and favor reduced susceptibility. Mechanistic studies in non-
                    <jats:italic>Mundinia</jats:italic>
                    species identify transport disruption, lipid and sterol remodeling, mitochondrial stress adaptation, redox buffering, and host-parasite effects as resistance-relevant axes, while regional data raise concern for amphotericin B-associated reduced miltefosine susceptibility in
                    <jats:italic>L. martiniquensis</jats:italic>
                    . Wider implementation should therefore be linked to species-resolved diagnostics, baseline susceptibility testing, longitudinal phenotype-genotype surveillance, drug stewardship, and One Health monitoring. Miltefosine should be considered a rational but carefully monitored therapeutic addition for emerging Southeast Asian leishmaniasis.
                  </jats:p>
BT - PLOS Neglected Tropical Diseases
DA - 07/2026
DO - 10.1371/journal.pntd.0014555
IS - 7
LA - ENG
M3 - Article
N2 - <jats:p>
                    Miltefosine, the only oral antileishmanial drug with regulatory approval, has expanded treatment options in several endemic settings but shows variable efficacy across
                    <jats:italic>Leishmania</jats:italic>
                    species, clinical forms, and host immune contexts. In Southeast Asia, where
                    <jats:italic>Leishmania</jats:italic>
                    (
                    <jats:italic>Mundinia</jats:italic>
                    )
                    <jats:italic>martiniquensis</jats:italic>
                    and
                    <jats:italic>L.</jats:italic>
                    (
                    <jats:italic>M.</jats:italic>
                    )
                    <jats:italic>orientalis</jats:italic>
                     are increasingly reported, amphotericin B formulations remain the main treatment despite toxicity, relapse, and implementation constraints. This review evaluates miltefosine’s clinical relevance, mechanisms of action, and resistance pathways, with emphasis on Thailand and neighboring Southeast Asian settings. A Thai compassionate-use case using miltefosine with liposomal amphotericin B for refractory
                    <jats:italic>L. martiniquensis</jats:italic>
                    infection achieved repeated clinical improvement and culture negativity after combination induction, although monotherapy was insufficient to maintain remission in advanced immunosuppression. Evidence from other endemic regions indicates that poor adherence, unregulated access, prolonged subtherapeutic exposure, and inadequate monitoring can reduce treatment durability and favor reduced susceptibility. Mechanistic studies in non-
                    <jats:italic>Mundinia</jats:italic>
                    species identify transport disruption, lipid and sterol remodeling, mitochondrial stress adaptation, redox buffering, and host-parasite effects as resistance-relevant axes, while regional data raise concern for amphotericin B-associated reduced miltefosine susceptibility in
                    <jats:italic>L. martiniquensis</jats:italic>
                    . Wider implementation should therefore be linked to species-resolved diagnostics, baseline susceptibility testing, longitudinal phenotype-genotype surveillance, drug stewardship, and One Health monitoring. Miltefosine should be considered a rational but carefully monitored therapeutic addition for emerging Southeast Asian leishmaniasis.
                  </jats:p>
PB - Public Library of Science (PLoS)
PY - 2026
SP - 1 
EP -  32
T2 - PLOS Neglected Tropical Diseases
TI - Miltefosine and emerging Leishmania (Mundinia) in Southeast Asia: Molecular insights, therapeutic challenges, and future strategic implementation
UR - https://journals.plos.org/plosntds/article/file?id=10.1371/journal.pntd.0014555&type=printable
VL - 20
SN - 1935-2735
ER -