Haemoflagellates Leishmaniasis & Trypanosomiasis

Different stages of Haemoflagellates

Promastigotes of Leishmania Amastigote of Leishmania

The life cycle of Leishmania

Leishmania Parasites and Diseases SPECIES Cutaneous leishmaniasis Leishmania tropica* Leishmania major* Leishmania aethiopica Leishmania mexicana Mucocutaneous leishmaniasis Leishmania braziliensis Visceral leishmaniasis Leishmania donovani* Leishmania infantum* Leishmania chagasi * Endemic in Saudi Arabia

World distribution of Visceral Leishmaniasis

Sand fly

Amastigotes of Leishmania

Promastigotes of Leishmania

lesion

lesion

lesion

Clinical types of cutaneous leishmaniasis Leishmania major: Zoonotic cutaneous leishmaniasis: wet lesions with severe reaction Leishmania tropica: Anthroponotic cutaneous leishmaniasis: Dry lesions with minimal ulceration Oriental sore (most common) classical self-limited ulcer

Uncommon types Diffuse cutaneous leishmaniasis (DCL): Caused by L. aethiopica, diffuse nodular non-ulcerating lesions. Low immunity to Leishmania antigens, numerous parasites. Leishmaniasis recidiva (lupoid leishmaniasis): Severe immunological reaction to leishmania antigen leading to persistent dry skin lesions, few parasites.

Diffuse cutaneous leishmaniasis Leishmaniasis recidiva

cutaneous leishmaniasis Diagnosis: Smear: Giemsa stain – microscopy for LD bodies (amastigotes) Biopsy: microscopy for LD bodies or culture in NNN medium for promastigotes

NNN medium

Treatment No treatment – self-healing lesions Medical: Surgical: Pentavalent antimony (Pentostam), Amphotericin B +/- Antibiotics for secondary bacterial infection. Surgical: Cryosurgery Excision Curettage

Pentostam ( sodium stibogluconate) for treatment of all types of leishmaniasis

Visceral leishmaniasis There are geographical variations. The diseases is called kala-azar Leishmania infantum mainly affect children Leishmania donovani mainly affects adults

Presentation Fever Splenomegaly, hepatomegaly, hepatosplenomegaly Weight loss Anaemia Epistaxis Cough Diarrhoea

Untreated disease can be fatal After recovery it might produce a condition called post kala-azar dermal leishmaniasis (PKDL)

Fever 2 times a day due to kala-azar

Hepatosplenomegaly in visceral leishmaniasis

Mucocutaneous leishmaniasis

Visceral leishmaniasis Diagnosis Parasitological diagnosis: METHOD Bone marrow aspirate 1. microscopy Splenic aspirate 2. culture in NNN medium Lymph node Tissue biopsy

Bone marrow aspiration Bone marrow amastigotes

(2) Immunological Diagnosis: Specific serologic tests: Direct Agglutination Test (DAT), ELISA, IFAT Skin test (leishmanin test) for survey of populations and follow-up after treatment. Non specific detection of hypergammaglobulinaem by formaldehyde (formol-gel) test or by electrophoresis.

DAT test ELISA test

Formol-gel

Treatment: Pentavalent antimony- sodium stibogluconate (Pentostam) Amphotericin B Treatment of complications: Anaemia Bleeding Infections etc.

Post-kalazar dermal leishmaniasis (PKDL)

Trypanosomiases

African Trypanosomiasis Life cycle of Trypanosoma brucei gambiense & T. b. rhodesiense

African sleeping sickness Trypanosoma brucei rhodesiense: East Africa, wild and domestic animal reservoirs Trypanosoma brucei gambiense: West and Central Africa, mainly human infection

Animal reservoir hosts for African sleeping sickness

Tsetse fly

Pathology and clinical picture Skin stage: chancre. Haematolymphatic stage: generalized lymphadenopathy, anaemia, generalized organ involvement. Central nervous system stage (CNS): Meningoencephalitis. (Development of the disease more rapid in Trypanosoma brucei rhodesiense)

chancre

Winterbottom’s stage

3rd stage CNS

Lymph node aspirate

trypanosoma

CSF

AMERICAN TRYPANOSOMIASIS LIFE CYCLE OF Trypanosoma cruzi

Reduviid (Triatomine) bug

Diagnosis Blood film Serology: IFAT Xenodiagnosis: feeding bugs on a suspected cases.

T. cruzi causes cutaneous stage (chagoma)

Ocular lesion (Romana’ sign)

C-shape

TREATMENT African trypanosomiasis For early infection pentamidine suramin For late infection eflornithine (Diflouromethylornithine- DFMO) American trypanosomiasis (Chaga’s disease) benznidazole nifurtimox

Trichomonas vaginalis trophozoites

Trichomonas vaginalis

Trichomonas vaginalis Transmission: sexual intercourse contact with contaminated objects.

Trichomoniasis Pathology Female: vaginitis, profuse thin yellowish discharge with bad smell Male: invasion of urethra, prostate and seminal vesicles, causing urethritis but mostly asymptomatic.

Signs and Symptoms of Trichomoniasis in Women Sign/Symptom Percent of Patients Asymptomatic ≤ 50% Vaginal/vulvar erythema (redness) 75% Frothy, yellow/green discharge 25% Vulvar itching 20-50% Strawberry cervix < 2% Vaginal odor 60% pH > 5 60-90% Dyspareunia (pain during sexual intercourse) < 25% Dysuria (pain during urination)

Signs and Symptoms of Trichomoniasis in Men Sign/Symptom % of Patients Asymptomatic > 50% Urethral discharge 65-100% Pruritus (itching) 98.5% Dysuria (pain during urination) 5.5%

Trichomoniasis Diagnosis Identification of parasite by microscopy of discharge. Examination of vaginal or urethral discharge for T. vaginalis

Trichomonas vaginalis

Trichomonas vaginalis

Trichomoniasis Treatment: metronidazole (flagyl). Note: Treat sexual partner because infection is mostly asymptomatic in males.