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Koohsar F, Kalani H, Livani F, Jorjani O N, Yadagiri G, Ahmadi A et al . In vitro anti-leishmanial effects of garlic extract on Leishmania major: A Systematic Review. mljgoums 2024; 18 (3) :21-24
URL: http://mlj.goums.ac.ir/article-1-1600-en.html
URL: http://mlj.goums.ac.ir/article-1-1600-en.html
Faramarz Koohsar1 
, Hamed Kalani2 , Fatemeh Livani2 , Oghol Niaz Jorjani1 , Ganesh Yadagiri3 , Alireza Ahmadi1 , Roghiyeh Faridnia 4
, Hamed Kalani2 , Fatemeh Livani2 , Oghol Niaz Jorjani1 , Ganesh Yadagiri3 , Alireza Ahmadi1 , Roghiyeh Faridnia 4
1- Laboratory Sciences Research Center, Golestan University of Medical Sciences, Gorgan, Iran
2- Infectious Diseases Research Center, Golestan University of Medical Sciences, Gorgan, Iran
3- Department of Veterinary Biosciences, College of Veterinary Medicine, The Ohio State University, Columbus, United States
4- Laboratory Sciences Research Center, Golestan University of Medical Sciences, Gorgan, Iran ,r_faridnia400@yahoo.com
2- Infectious Diseases Research Center, Golestan University of Medical Sciences, Gorgan, Iran
3- Department of Veterinary Biosciences, College of Veterinary Medicine, The Ohio State University, Columbus, United States
4- Laboratory Sciences Research Center, Golestan University of Medical Sciences, Gorgan, Iran ,
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Introduction
Leishmaniasis is a vector-borne parasitic disease caused by an obligate intracellular protozoan. It is a public health problem in many tropical and subtropical countries. Annually, the frequency of leishmaniasis is evaluated to be 0.7-1.3 million cases globally, though the real number of infected cases is estimated to be 6- to 10-fold higher than that reported (1). The disease includes a variety of clinical syndromes, including cutaneous leishmaniasis (CL), mucocutaneous leishmaniasis (MCL), and visceral leishmaniasis (VL). CL is the most common form of leishmaniasis. It is caused by over 15 different species of the protozoan parasite Leishmania. This microorganism is transmitted to humans by infected female sandflies (2). CL can have disturbing effects on local communities. It causes scarring skin lesions that can leave life-long scars and lead to severe social dishonor, especially for women and children (3).
Currently, the treatment of cutaneous leishmaniasis is based on intralesional injection or oral medication, along with cryotherapy, topical controlled heat, CO2 laser, and photodynamic therapy. Antimonial drugs have been widely used for CL treatment (4). Despite the high prevalence of CL, there is still a lack of appropriate prevention, control, and treatment methods. In various cultures and countries, local medicinal plants are utilized for the treatment of diseases, particularly leishmaniasis. Currently, extensive research is being conducted on treatment methods for leishmaniasis. Medicinal plants have been traditionally used in medicine to treat or reduce the severity of CL lesions (5).
Garlic belongs to the Liliaceae family and its scientific name is Allium sativum (6). The antibiotic properties of garlic have been recognized for a long time. Several studies have been done on the antimycotic properties of garlic (7). In recent years, a few studies have been performed on the effects of garlic extract for the treatment of cutaneous leishmaniasis. Current drugs, such as glucantime, have several side effects and lead to direct cellular damage. If an herbal-based drug reduces Leishmania by augmenting the immune system, it has the potential to possess a wider margin of safety (8). This study aimed to investigate the effects of in vitro systematic review of the effects of garlic (Allium sativum) and its compounds on Leishmania major.
Methods
Information sources and search strategy
The current study was conducted according to the PRISMA guideline (9). Five English databases (PubMed, Google Scholar, Embase, Scopus, and Web of Science) were searched until the end of December 2022. No further search (e.g., from reference lists of the papers) was performed. The search was carried out in the English language. The syntax of all databases has been presented in Table 1. The articles were included in this study in which the effect of garlic extract or at least one of its compounds was examined on Leishmania parasites. The studies with poor methodology, inadequate information, inappropriate analysis, and confusing presentation were excluded from the current study. The search strategy flowchart is presented in Figure 1.
Quality assessment
The quality assessment tool was developed by the authors specifically in which eleven questions were answered as follows: 1) Is the use of garlic extract or the name of its active compound mentioned in the study? 2) Is the method of obtaining the extract or its active composition clearly stated? 3) Is it mentioned that the parasite was isolated from the patient or is it a standard strain? 4) Is the method of passage and maintenance of the parasite mentioned? 5) Is the name of the parasite species mentioned? 6) Are the dilutions in a wide range used to determine the IC50, or are a few given dilutions used? 7) Is there a formula or software for determining IC50? 8) Is the name of the cell line for transforming the parasite into amastigote form stated? 9) Is the method of transforming the parasite into amastigote form clearly stated? 10) Is cell cytotoxicity 50 (IC50) and subsequent selectivity index (SI) calculated? 11) Is there an emphasis on a particular result, or the results are magnified? Each question is answered with “Yes”, “Unclear”, and “No”, and 1, 0.5, and 0 scores are given to each question, respectively. The articles that have scores ≥8 are evaluated for good quality and are included in the study.
Data extraction
Data were extracted from each of the selected articles by two independent authors (HK and RF). The interrater reliability was 100% and no divergence was observed. The extracted data were: the extracted data were as follows: author, garlic parts/components, solvent, cell type, treatment concentrations, examination times, measured objects (Examination method), positive control (Dose), important results, cytotoxicity for host cell, and effectiveness of garlic alone.
Results
The selected studies are shown in Figure 1. Accordingly, 198 articles were selected in the search step, of which five eligible articles were included for examination. The most used solvent for the preparation of garlic extract was distilled water (60%, n = 3), followed by methanol (40%, n = 2). In these studies, the bulb of garlic is mostly used (80%, n = 4). Cell type of J774 was used in only one study (20%, n = 1), and murine peritoneal macrophages were used in the other studies (80%, n = 4). The effect of garlic on Leishmania major was strong (80%, n = 4), and had the greatest effect. More details are presented in Table 2.
Among the reviewed articles, five articles were evaluated as good based on quality, and the answers to the questions for all the articles are pooled and presented in Figure 2.
Discussion
Garlic belongs to the Liliaceae family and is systematically named Allium sativum. For a long time, the antibiotic properties of garlic have been recognized (15). The antibacterial effect of garlic on Gram-positive and negative bacteria has been well established for a long time. Several studies have been conducted on the antifungal properties of garlic (16).
In recent years, a few studies have been done on the effects of garlic extract on the treatment of cutaneous leishmaniasis. It has been proposed that garlic reduces the advancement of leishmaniasis by promoting the growth of the immune system. Identifying the specific component of garlic extract, that is effective in treating CL, is important for approving a cure protocol. Current drugs, such as glucantime, have several side effects and lead to direct cellular damage. If an herbal-based drug can eliminate Leishmania by enhancing the development of the immune system (17). So far, there is no appropriate vaccine or drug to prevent the parasite. Studies have shown that garlic extract or its active compounds can increase cellular immune responses, which play an important role in inhibiting the Leishmania parasite. This is associated with the activation of macrophages and increased interferon-gamma (IFN-γ) levels and nitric oxide (NO) production (18). NO plays an important role in controlling the Leishmania parasite, so the amount of NO produced has an inverse relationship with the size of the lesion caused by the Leishmania parasite, and hence it plays an important role in healing the Leishmania lesion (10). In addition to increasing the production of cytokines, garlic extract increases phagocytosis by macrophages, which is very important for exposing antigens to the immune system (14). Additionally, in line with recent studies, it appears that garlic extract can increase the IgG2a-to-IgG1 ratio, highlighting the increase in responses related to the cellular immune system. This system is capable of controlling infection when challenged with an ulcer-causing strain of Leishmania (19). The most effective response from the cellular immune system was observed at a concentration of 37 mg/mL of garlic extract within 48 hours (19). This concentration of garlic extract has a toxic effect on the parasite, which this is associated with an increase in the expression of IFN-γ levels and inducible nitric oxide synthase (iNOS) genes (8). The results of another study showed that this concentration of garlic extract is significantly able to induce apoptosis of the parasite in the in vitro situation (20), and this is probably the mechanism of anti-Leishmanial action of garlic extract.
Conclusion
According to the studies, the effect of different combinations of garlic on the Leishmania parasite has been shown; however, the exact mechanism of the anti-leishmanial effect of garlic has not been determined; thus, this issue needs further investigation. Further studies are necessary to investigate the combined effect of garlic extract and glucantime, which in case of acceptable results can be used to reduce the dose of glucantime and its side effects.
Acknowledgement
None.
Funding sources
The Vice-chancellor of Research at Golestan University of Medical Sciences funded this study (Grant No. 112524).
Ethical statement
Not applicable.
Conflicts of interest
The authors declare that there is no conflict of interest.
Author contributions
Faramarz Koohsar designed the study and read title and abstract of the articles; Hamed Kalani searched the literature; Fatemeh Livani read title and abstract of the articles and extracted the data; Oghol Niaz Jorjani wrote the draft of the manuscript; Ganesh Yadagiri performed the quality assessment. Alireza Ahmadi selected the included articles; Roghiyeh Faridnia read the selected articles, performed the quality assessment, and finalized the manuscript. All authors read and approved the final manuscript.
Leishmaniasis is a vector-borne parasitic disease caused by an obligate intracellular protozoan. It is a public health problem in many tropical and subtropical countries. Annually, the frequency of leishmaniasis is evaluated to be 0.7-1.3 million cases globally, though the real number of infected cases is estimated to be 6- to 10-fold higher than that reported (1). The disease includes a variety of clinical syndromes, including cutaneous leishmaniasis (CL), mucocutaneous leishmaniasis (MCL), and visceral leishmaniasis (VL). CL is the most common form of leishmaniasis. It is caused by over 15 different species of the protozoan parasite Leishmania. This microorganism is transmitted to humans by infected female sandflies (2). CL can have disturbing effects on local communities. It causes scarring skin lesions that can leave life-long scars and lead to severe social dishonor, especially for women and children (3).
Currently, the treatment of cutaneous leishmaniasis is based on intralesional injection or oral medication, along with cryotherapy, topical controlled heat, CO2 laser, and photodynamic therapy. Antimonial drugs have been widely used for CL treatment (4). Despite the high prevalence of CL, there is still a lack of appropriate prevention, control, and treatment methods. In various cultures and countries, local medicinal plants are utilized for the treatment of diseases, particularly leishmaniasis. Currently, extensive research is being conducted on treatment methods for leishmaniasis. Medicinal plants have been traditionally used in medicine to treat or reduce the severity of CL lesions (5).
Garlic belongs to the Liliaceae family and its scientific name is Allium sativum (6). The antibiotic properties of garlic have been recognized for a long time. Several studies have been done on the antimycotic properties of garlic (7). In recent years, a few studies have been performed on the effects of garlic extract for the treatment of cutaneous leishmaniasis. Current drugs, such as glucantime, have several side effects and lead to direct cellular damage. If an herbal-based drug reduces Leishmania by augmenting the immune system, it has the potential to possess a wider margin of safety (8). This study aimed to investigate the effects of in vitro systematic review of the effects of garlic (Allium sativum) and its compounds on Leishmania major.
Methods
Information sources and search strategy
The current study was conducted according to the PRISMA guideline (9). Five English databases (PubMed, Google Scholar, Embase, Scopus, and Web of Science) were searched until the end of December 2022. No further search (e.g., from reference lists of the papers) was performed. The search was carried out in the English language. The syntax of all databases has been presented in Table 1. The articles were included in this study in which the effect of garlic extract or at least one of its compounds was examined on Leishmania parasites. The studies with poor methodology, inadequate information, inappropriate analysis, and confusing presentation were excluded from the current study. The search strategy flowchart is presented in Figure 1.
|
Table 1. The syntax for each of the databases used in the current systematic review
 |
Quality assessment
The quality assessment tool was developed by the authors specifically in which eleven questions were answered as follows: 1) Is the use of garlic extract or the name of its active compound mentioned in the study? 2) Is the method of obtaining the extract or its active composition clearly stated? 3) Is it mentioned that the parasite was isolated from the patient or is it a standard strain? 4) Is the method of passage and maintenance of the parasite mentioned? 5) Is the name of the parasite species mentioned? 6) Are the dilutions in a wide range used to determine the IC50, or are a few given dilutions used? 7) Is there a formula or software for determining IC50? 8) Is the name of the cell line for transforming the parasite into amastigote form stated? 9) Is the method of transforming the parasite into amastigote form clearly stated? 10) Is cell cytotoxicity 50 (IC50) and subsequent selectivity index (SI) calculated? 11) Is there an emphasis on a particular result, or the results are magnified? Each question is answered with “Yes”, “Unclear”, and “No”, and 1, 0.5, and 0 scores are given to each question, respectively. The articles that have scores ≥8 are evaluated for good quality and are included in the study.
Data extraction
Data were extracted from each of the selected articles by two independent authors (HK and RF). The interrater reliability was 100% and no divergence was observed. The extracted data were: the extracted data were as follows: author, garlic parts/components, solvent, cell type, treatment concentrations, examination times, measured objects (Examination method), positive control (Dose), important results, cytotoxicity for host cell, and effectiveness of garlic alone.
Results
The selected studies are shown in Figure 1. Accordingly, 198 articles were selected in the search step, of which five eligible articles were included for examination. The most used solvent for the preparation of garlic extract was distilled water (60%, n = 3), followed by methanol (40%, n = 2). In these studies, the bulb of garlic is mostly used (80%, n = 4). Cell type of J774 was used in only one study (20%, n = 1), and murine peritoneal macrophages were used in the other studies (80%, n = 4). The effect of garlic on Leishmania major was strong (80%, n = 4), and had the greatest effect. More details are presented in Table 2.
Among the reviewed articles, five articles were evaluated as good based on quality, and the answers to the questions for all the articles are pooled and presented in Figure 2.
Table 2. In vitro Leishmania major effects of garlic (Allium sativum) or its compounds in the reviewed studies |
Discussion
Garlic belongs to the Liliaceae family and is systematically named Allium sativum. For a long time, the antibiotic properties of garlic have been recognized (15). The antibacterial effect of garlic on Gram-positive and negative bacteria has been well established for a long time. Several studies have been conducted on the antifungal properties of garlic (16).
In recent years, a few studies have been done on the effects of garlic extract on the treatment of cutaneous leishmaniasis. It has been proposed that garlic reduces the advancement of leishmaniasis by promoting the growth of the immune system. Identifying the specific component of garlic extract, that is effective in treating CL, is important for approving a cure protocol. Current drugs, such as glucantime, have several side effects and lead to direct cellular damage. If an herbal-based drug can eliminate Leishmania by enhancing the development of the immune system (17). So far, there is no appropriate vaccine or drug to prevent the parasite. Studies have shown that garlic extract or its active compounds can increase cellular immune responses, which play an important role in inhibiting the Leishmania parasite. This is associated with the activation of macrophages and increased interferon-gamma (IFN-γ) levels and nitric oxide (NO) production (18). NO plays an important role in controlling the Leishmania parasite, so the amount of NO produced has an inverse relationship with the size of the lesion caused by the Leishmania parasite, and hence it plays an important role in healing the Leishmania lesion (10). In addition to increasing the production of cytokines, garlic extract increases phagocytosis by macrophages, which is very important for exposing antigens to the immune system (14). Additionally, in line with recent studies, it appears that garlic extract can increase the IgG2a-to-IgG1 ratio, highlighting the increase in responses related to the cellular immune system. This system is capable of controlling infection when challenged with an ulcer-causing strain of Leishmania (19). The most effective response from the cellular immune system was observed at a concentration of 37 mg/mL of garlic extract within 48 hours (19). This concentration of garlic extract has a toxic effect on the parasite, which this is associated with an increase in the expression of IFN-γ levels and inducible nitric oxide synthase (iNOS) genes (8). The results of another study showed that this concentration of garlic extract is significantly able to induce apoptosis of the parasite in the in vitro situation (20), and this is probably the mechanism of anti-Leishmanial action of garlic extract.
Conclusion
According to the studies, the effect of different combinations of garlic on the Leishmania parasite has been shown; however, the exact mechanism of the anti-leishmanial effect of garlic has not been determined; thus, this issue needs further investigation. Further studies are necessary to investigate the combined effect of garlic extract and glucantime, which in case of acceptable results can be used to reduce the dose of glucantime and its side effects.
Acknowledgement
None.
Funding sources
The Vice-chancellor of Research at Golestan University of Medical Sciences funded this study (Grant No. 112524).
Ethical statement
Not applicable.
Conflicts of interest
The authors declare that there is no conflict of interest.
Author contributions
Faramarz Koohsar designed the study and read title and abstract of the articles; Hamed Kalani searched the literature; Fatemeh Livani read title and abstract of the articles and extracted the data; Oghol Niaz Jorjani wrote the draft of the manuscript; Ganesh Yadagiri performed the quality assessment. Alireza Ahmadi selected the included articles; Roghiyeh Faridnia read the selected articles, performed the quality assessment, and finalized the manuscript. All authors read and approved the final manuscript.
Research Article: Systematic Review |
Subject:
Parasitology
Received: 2022/12/5 | Accepted: 2023/07/31 | Published: 2024/05/10 | ePublished: 2024/05/10
Received: 2022/12/5 | Accepted: 2023/07/31 | Published: 2024/05/10 | ePublished: 2024/05/10
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