1. Leishmaniasis

2. Definition and causative agent:
Group of diseases caused by protozoa of the genus Leishmania, convey to humans by female phlebotomine sandifly in which the flagellate (promastigotes) forms of leishmania develop.
In human, the leishmania are found in the cells (obligatory intracellular parasite) of the monocytes/macrophage systems oval form known as amastigotes

3. The leishmaniases are caused by 20 species pathogenic for humans belonging to the genus Leishmania, a protozoa transmitted by the bite of a tiny 2 to 3 millimetre-long insect vector, the phlebotomine sandfly.
Of 500 known phlebotomine species, only some 30 of them have been positively identified as vectors of the disease.

4. In its search for blood (usually in the evening and at night), the female sand fly covers a radius of a few to several hundred meters around its habitat.
The WHO has estimated that more than 350 million people at risk of Leishmaniasis. men, women and children in 88 countries around the world.
CASE DEFINITION by WHO:
A person showing clinical signs of leishmaniasis with parasitological confirmation and/ or for mucosal leishmaniasis only, serological diagnosis

5. The leishmaniases are parasitic diseases with a wide range of clinical symptoms: cutaneous, mucocutaneous and visceral.
Infectious agents:
Eastern hemisphere: L.tropica, L. major , L. aethiopica.
Western hemisphere: L. braziliensis and L. mexicana complexes.
In Iraq, especially in middle and southern governorates, Leishmaniasis was considered as endemic disease since long time. Leishmaniasis occurs mostly in rural areas of warm and tropical countries where public health infrastructures were inadequate.

6. Leishmania can cause:
Cutaneous Leishmaniasis; "Baghdad boil", "Delhi boil“
Definition: A polymorphic protozoan disease of skin (some time involve the mucus membrane in Brazil & Mexico). The disease started as papule (on exposed skin) that enlarge→ indolent ulcer (single or multiple) → may heal spontaneously or with treatment → disfiguring scar. Recurrence of cutaneous lesion may occur

7. The disease can produce a large number of lesions - sometimes up to causing serious disability and invariably leaving the patient permanently scarred, a stigma which can cause serious social prejudice

8. Infectious agent: Leishmania tropica (Eastern hemisphere) and Leishmania Braziliansis & Mexicana (Western hemisphere).
Incubation period: 1Wk-1Month.
Reservoir: Human, rodent, carnivores including domestic dogs.
Mode of transmission: Through the bite of the infected female phlebotomine (sandifly).
Susceptibility: is general, recurrent infection can occur.
Diagnosis: Direct microscopical examination in stained specimen from lesion. IFAT or ELISA is unsuitable for Cutaneous type.

9. Prevention:
Primary: - Public education (disease impact, transmission, prevention).
- Periodic application of insecticide with residual action.
- Rodent and dog control measures.
Secondary: - Report to local health authorities.
- Investigation of contact and source of infection.
- Detect cases systematically and treat periodically.
- Specific treatment: Pentostam either by local infiltration (simple lesion) or systemic route for multiple lesions.

10. Effective disease surveillance is important
Effective disease surveillance is important. Early detection and treatment of cases helps reduce transmission and helps monitor the spread and burden of disease.

11. Mucocutaneous forms
In mucocutaneous forms of leishmaniasis, lesions can lead to partial or total destruction of the mucous membranes of the nose, mouth and throat cavities and surrounding tissues. These disabling and degrading forms of leishmaniasis can result in victims being humiliated and cast out from society.

13. Visceral Leishmaniasis; "Kala-azar", "Dum-Dum fever", "Black fever".
A chronic systemic disease caused by intracellular parasite of the genus Leishmania characterized by prolong fever, hepato-splenomegaly lymphadenopathy, anemia, leukopenia, thrombocytopenia, and progressive emaciation and weakness. If left untreated, the fatality rate in developing countries can be as high as 100% within 2 years. post- kala-azar dermal leishmaniasis consists of macular, papular and/or nodular skin lesions that occurs weeks to years after apparent cure of systemic disease.

14. The disease is prevalent in the Mediterranean and red sea littorals, India China, and Africa. In Europe, reoccurrence of the disease in certain foci (south of Spine and France) as a result of AIDS epidemic. In Iraq, the disease mainly found in middle and southern governorates, it affects children <5 years old.

15. Infectious agent: Leishmania donavani, Leishmania infantum.
Incubation period: 2-6 Months. But can be extend to many years.
Reservoir: Human, rodent, carnivores including domestic dogs.
Mode of transmission: Through the bite of the infected female phlebotomine (sandifly).
Susceptibility: is general, recurrent infection can occur.
Period of communicability:
Not directly transmitted from person to person, but infectious to sandfly as long as parasite remain in lesions.in untreated cases usually a few months to 2 years.
Eventual spontaneous healing occurs in most cases, but rate of healing varies by species

16. Diagnosis:
Bone marrow exam → demonstration of intracellular amastigotes in stained smear.
Stained specimen from spleen, liver LN or blood.
IFAT or ELISA test.
Prevention: same as cutan. Leish.

17. Burden of disease
Magnitude of the problem
Leishmaniasis is a poverty-related disease. It affects the poorest of the poor and is associated with malnutrition, displacement, poor housing, and illiteracy, and gender discrimination, weakness of the immune system and lack of resources. Leishmaniasis is also linked to environmental changes,* such as deforestation, building of dams, new irrigation schemes and urbanization, and the accompanying migration of non-immune people to endemic areas.

18. Leishmania/HIV co-infection
One of the major threats to control of visceral leishmaniasis (VL) is its interaction with HIV infection. VL has emerged as an important opportunistic infection associated with HIV. In areas endemic for VL, many people have asymptomatic infection. A concomitant HIV infection increases the risk of developing active VL by between 100 and 2320 times. In southern Europe, up to 70% of cases of visceral leishmaniasis in adults are associated with HIV infection.

19. Treatment:
The treatment of leishmaniasis depends on several factors including type of disease, parasite species, geographic location. Leishmaniasis is a treatable and curable disease. All patients diagnosed as visceral leishmaniasis require prompt and complete treatment. Mainly pentavalent antimonials,pentamedine is used as a second line drug for coetaneous leish.