By Raghda El-Sayed Farag Assistant prof. of Tropical Medicine Leishmaniasis By Raghda El-Sayed Farag Assistant prof. of Tropical Medicine

(Haemo-somatic flagellates) Leishmania (Haemo-somatic flagellates) These are flagellated protozoa transmitted by insect bite (sand flies) They infect blood and tissues of human and reservoir hosts. Three species infecting man, with the same morphology and L. cycle in insect, but differ in geographical distribution, vector, C/P and culture characteristics.

Leishmaniasis - Leishmaniasis is a parasitic disease transmitted by the bite of sand flies. (Pholobotomus or Lutzomyia) - Found in parts of at least 88 countries including the Middle East - Different species of Leishmania cause different forms of disease

Clinical Types Of Leishmaniasis 1-Visceral leishmaniasis: A) Old world visceral leishmaniasis: L. donovani complex (L. donovani, L. infantum) B) New world visceral leishmaniasis : L. chagasi L. amazonensis. 2-Cutaneous leishmaniasis: L. tropica complex (L. major, L. tropica) 3-Mucocutaneous leishmaniasis: L. braziliensis complex

Prevalence About 1.5 million new cases of cutaneous leishmaniasis occur in the world each year 500,000 new cases of visceral leishmaniasis estimated to occur each year

Endemic Areas for Leishmaniasis Highlighted areas are parts of the world where leishmaniasis has been reported. Taken from British Medical Journal 2003 326:378 BMJ 2003;326:378

Some species tend to cause cutaneous leishmaniasis (e. g. , L Some species tend to cause cutaneous leishmaniasis (e.g., L. major and L.tropica), whereas some species tend to cause visceral leishmaniasis (e.g., L. infantum and L donovani)

Morphology Promasitogte Amastigote Digenetic Life Cycle Motile Midgut Insect Amastigote Non-motile Intracellular Mammalian stage

Morphology : 1-In RECs all over the human body & reservoir hosts, it takes amastigote forms (intracellular in macrophages).

2- In insect vector and culture, it takes the promastigote form.

Promastigote

LIFE CYCLE

Visceral Leishmaniasis kala-azar, black fever, Dumdum fever 1903 1920 1931 William Leishman Pentavalent antimony Experimental transmission Old world visceral leishmaniasis: L. donovani complex (L. donovani, L. infantum) B) New world visceral leishmaniasis : L. chagasi L. amazonensis.

Life cycle: Habitat: In R.E.Cs of viscera, mainly cells of spleen, Kupffer cells of liver, bone marrow, intestinal mucosa of large intestine& mesenteric L.N. In endothelial cells of kidney , suprarenal capsules, lungs, meninges and in CSF. In macrophages of the intestinal wall, circulating blood, heart and in nasal secretions.

Reservoir hosts: Dogs, rodents and desert gerbils. Definitive host: Man. Reservoir hosts: Dogs, rodents and desert gerbils. Insect vectors: are female sand flies; Phelobotomus or Lutzomyia. Infective stage: Promastigotes in buccal cavity and pharynx of sand fly. Mode of infection: 1. Bite of infected vector. 2.Blood transfusion or organ transplantation. 3.Direct in epidemics from man to man by nasal secretions. 4. Congenital. 5. Accidental in laboratory.

Geographical distibution: L. donovani: the disease is endemic in India, Pakistan, Indonesia, Thailand, Central Africa and Sudan. L. infantum: Mediterranean areas (North Africa, Southern Europe). L. chagasi: in the Central and South America.

Promastigote Amasitgote Initial Infection Similar in all species start by Inoculation of promastigotes ↓ Inflammation & chemotaxis Receptor mediated phagocytosis by macrophage Promastigote Amasitgote Transformation

Parasite Spread Macrophage lysis & parasite release Lymphatic spread Blood spread ↓ Target organs REC in Skin/lymph nodes/spleen/liver/kidneys bone marrow

Pathogenesis & Symptomatology: Incubation period: 1-3 ms, may be short as 2 wks. A primary lesion at the site of infection is rarely observed, but minute papules have been described in infants, and in Africa dermal lesions of the legs or arms can occur (dermal leishmaniomas). The phagocytosed parasites are present in small numbers in the blood, but are numerous in the R.E.Cs of the affected organs with marked hyperplasia.

The most important sign is fever (twice-daily rise), mailase, headache, sweating, weakness, weight loss, emaciation, non-productive cough, oedma, abdominal discomfort, hepatosplenomegaly, bleeding of mucous membrane of gums and nose. Diarrhea and dysentry are common (parasites in lymphoid macrophages in the intestinal submucosa).

Anemia, thrombocytopenia and neutropenia due to bone marrow infiltration. - Types of anemia: Aplastic: extensive multiplication of the parasite in bone marrow. Microcytic: lack of iron absorption from intestine. Macrocytic: hepatic damage and fatty infiltration of liver causing deficient storage of Vit.B12. Mucopurulent discharge containing leishmanial bodies.

In human hosts, response to infection by L In human hosts, response to infection by L. donovani varies, by the type of the patient’s immune reaction Of particular concern, according to the World Health Organization (WHO), is the emerging problem of HIV/VL co-infection

Pneumonia, tuberculosis, and dysentery are common in regions where leishmaniasis and, AIDS co infection present. These opportunistic infections are common cause of death

Two children with visceral leishmaniasis Two children with visceral leishmaniasis. The size of the spleen is marked on the abdomen. Normally the spleen does not protrude below the bottom rib. Photograph provided by COL Charles Oster

Post Kala Azar Dermal Leishmanoid Normally develops < 2 years after recovery Due to incomplete treatment Or as a Relapse Restricted to skin Rare but varies geographically (high incidance in India , Sudan)

Manifests first as small hypo-pigmented macules, papules, nodules, or facial erythema, measle-like lesions on the face, which gradually increase in size and spread over the body. Eventually the lesions may coalesce to form disfiguring, swollen structures resembling leprosy, or disseminated cutaneous leishmaniasis. occasionally causing blindness if they spread to the eyes.

Any type causing VL( Kala-azar) can lead to PKDL, so, it is commonly associated with L. donovani in India and Sudan.

Post Kala-Azar dermal leishmaniasis Dermal lesions may contain parasites in great numbers. 30

Diagnosis of Visceral Leishmaniasis Clinical: in endemic areas, leishmaniasis may be suspected in a patient who has: - Persistent, irregular or remittent fever (double daily peak). - Hepato-splenomegaly. - Pain from perisplenism. - Anaemia, leucopenia & emaciation. Laboratory: A- Direct: -1. Demonstration of amastigote in a smear stained by Leishman. Material is obtained from blood, bone marrow, L.N., splenic or liver biopsy, or nasal secretions.

2.Culture on NNN media: showing promastigotes in the form of rosette grouping.

B-Indirect: Montenegro (leishmanin) test: 0.1-2.0 ml. of antigen strains of human L.donovani or L. tropica is injected I.D. and the result read after 72 hrs. A delayed reaction develops in cured individuals. -The test is -ve in early cases due to depression of cellular immunity by the parasites, but becomes +ve 6-8 wks after completion of ttt.

ELISA, or direct agglutination test High level of specific serum IgG is indicator of visceral leishmaniasis.

Diagnosis - Living in or travelling to endemic area - Clinical signs & symptoms - Hypergammaglobulinemia ELISA/Formol gel - Bone marrow biopsy - Spleen or liver biopsy - Culture & Histology

Due to Similar morphology of all types we can need: Isoenzyme profiles - Zymodemes Monoclonal antibodies DNA detection by PCR

Treatment Supportive: -Good nursing. -Diet rich in vitamins, iron and liver support. -Proper antibiotics for 2ry bacterial infection. -Blood transfusion in case of sever anemia or bleeding. It is not known what species of visceral leishmaniasis is present in Iraq – WHO reports that children have L. infantum. During Desert Storm some of American soldiers were found to have visceral infection with L. tropica. Published studies of liposomal amphotericin for visceral leishmaniasis have not included patients with L. tropica so it is not known for sure that it would be effective but it is expected likely.

Specific : - Liposomal amphotericin-B (AmBisome® or Amphocil ) is the drug of choice 3 mg/kg per day on days 1-5, day 14 and day 21 - Antimony as Sodium stibogluconate (SSG) (Pentostam®) ) is an alternative therapy 20 mg/kg / day for 28 days repeated for 3 times - Patients suffering from both HIV and visceral leishmaniasis (VL) may be treated with acyclovir or pentamidine in conjunction with first-line antileishmanial therapies such as miltefosine and amphotericin-B (AmBisome) - Antimony as Sodium stibogluconate (SSG) alone or in combination with rifampicin is used for the treatment of PKLD for a long course of up to 4 months - Miltefosine , is a new drug for visceral and cutaneous leishmaniasis

Prevention: - Control of sand flies by destruction of their breeding grounds near human habitations and by the use of DDT (dichlorodiphenyltrichloroethane). - Avoid and destroy infective dogs ( reservior). - Treatment of infected persons. - Human beings can be protected by building houses with fine mesh screening (40 meshes / inch2) and by use of repellents

Cutaneous Leishmaniasis

Cutaneous Leishmaniasis A- Old world cutaneous leishmaniasis (Oriental Sore) Causative parasite: Leishmania tropica, L. major and L.ethiopica. Distribution: affects people in Middle and Far East, Mediterranean region, Asia and Africa.

B- New world cutaneous and mucocutaneous leishmaniasis Causative parasite: L. mexicana complex and L. braziliensis complex. Geographical distribution: Central and South America. Reservoir host: forest rodents, cats and dogs. Insect vector: Lutzomyia species.

Infection remains restricted to the initial site of infection (the bite site) 43

Cutaneous Leishmaniasis Most common form Characterized by one or more sores, papules or nodules on the skin Sores can change in size and appearance over time Often described as looking somewhat like a volcano with a raised edge and central crater Sores are usually painless but can become painful if secondarily infected Swollen lymph nodes may be present near the sores Some sores are covered by a scab or have not yet ulcerated so they may look like red raised plaques- sometimes with dry crust/scale

Cutaneous Leishmaniasis I.P: Most sores develop within a few weeks of the sandfly bite, however they can appear up to months later Skin sores of cutaneous leishmaniasis can heal on their own, but this can take months or even years Sores can leave significant scars and be disfiguring if they occur on the face If infection is from L. tropica it can spread to contiguous mucous membranes (upper lip to nose)

Cutaneous Leishmaniasis Mucosal leishmaniasis might not be noticed until years after the original cutaneous sores healed. The best way to prevent mucosal leishmaniasis is to ensure adequate treatment of the cutaneous infection especially where L. tropica is prevalent .

Patients with any of the following findings should be referred early to avoid long term complications: Big lesions (greater than an inch in size) Many lesions (3 or more) Sores on the face Sores on the hands and feet Sores over joints Cutaneous infection where L. tropica is prevalent

Photograph provided by COL Naomi Aronson

Photograph provided by COL Naomi Aronson

Small, raised lesion on trunk without significant oozing or scab. Photograph provided by COL Naomi Aronson

Multiple lesions on arm with a variety of appearances. Photograph provided by COL Naomi Aronson

Both lesions are leishmaniasis Note the raised border and wet appearance of the sore on the back of the hand. Sores over joints are very concerning as scarring with healing can lead to limited movement of joint. Photograph provided by COL Charles Oster

Back of hand. Note raised border and wet appearance. Patient has bacitracin ointment applied to lesion. Photograph provided by COL Naomi Aronson

Upper Eyelid. Note the dry, crusted/scabbed appearance which is different than previous sores shown. Photograph provided by COL Naomi Aronson

Close up of another dry, crusted lesion with concentric surrounding scale. This is a typical appearance for Old World Leishmaniasis. Photograph provided by COL Charles Oster

Three lesions on face. Raised and dry but not scabbed. Another different presentation. This was Leishmania tropica. Photograph provided by COL Charles Oster

Mucocutaneous Leishmaniasis

Mucocutaneous Leishmaniasis (Espundia) Occurs with Leishmania species from Central and South America: L. braziliensis Rarely associated with L. tropica in the Middle East - This type occurs if a cutaneous lesion on the face near the mouth or nose is not treated May occur months to years after original skin lesion Hard to confirm diagnosis (few parasites in the lesion). Lesions can be very disfiguring Much of the destruction is from a hyperimmune reaction to the Leishmania infection. There are not many parasites in the affected tissue so confirming the diagnosis can be difficult. This form of leishmaniasis would be unusual in soldiers infected in South West Asia.

Mucocutaneous Leishmaniasis The ulcers are painful, chronic, destructive and resistant to treatment. Greater deformity , erosion of the nasal septum, palate, larynx with loss of voice may occur. Death may develop from aspiration pneumonia, or septicemia ( 2 ry bacterial infection).

Photograph provided courtesy of COL Donald Skillman

Diagnosis: I.Clinical: typical lesion, with elevated and indurated margin of the ulcer. II.Laboratory: 1- Direct: Examination of material aspirated or scraped from the edge of the lesion and stained with Giemsa stain. Culture of the material on NNN media to see promastigotes. Animal inoculation.

2- Indirect: Montenegro test (leishmanin reaction): is an intradermal test using antigen from cultured promastigotes. -It is positive within several months after appearance of the lesion and remains +ve for years. -Generally 95% of cases show tests with induration and erythema of 4-5 mm or more in diameter, with delayed reaction after 3 days.

Treatment Cutaneous type 1. Local measures: Surgical excision especially if single lesions. Scraping (curettage). Heating of lesion to 50°C with infra red rays. Freezing therapy, using carbon dioxide snow. Chemical methods, by using topical preparations as 2% atebrine sulphate or 10% atebrine solution.

Antimony (Pentostam) as topical ointment. I.D. injection of interferon gamma around lesions promotes ulcer healing. Cleanliness to prevent secondary bacterial infection. Secondary infection needs local or systemic antibiotic medication particularly in muco-cutaneous type. 2. specific: Antimony (Pentostam) as topical ointment.

Amphotricin B: in severe resistant mucocutaneous type Antimony (Pentostam) is the drug of choice. Two or three courses may be needed. -20 days of intravenous therapy in case of mucocutaneous type - Fluconazole may decrease healing time in L. major infection - If the sores are 1-3 in number, treatment may be facilitated by local infiltration of the drug into the edges of the ulcers. Amphotricin B: in severe resistant mucocutaneous type