1. BLOOD AND TISSUE FLAGELLATES General Characters: 1. They live in blood and tissue of a human host. 2. They need a vector I.H. for transmission. 3. They move by a single flagellum arise from kinetoplast. The kinetoplast is formed of parabasal body and blepheroplast. 4. They multiply by longitudinal binary fission (the kinetoplast divides first followed by the cytoplasm).

2. 5. They may take one of the following forms: Promastigote: Promastigote:

3. Epimastigote: Epimastigote:

4. Trypomastigote: Trypomastigote:

5. Amastigote: Amastigote: 6. They include: Leishmania, Trypanosoma, Plasmodium, Toxoplasma, Babesia.

6. Visceral leishmaniasis Leishmania donovani complex is the causative organism of visceral leishmaniasis (Kala_Azar, black sickness or dumdum fever). There are 3 members in this group: Leishmania infantum: causing infantile kala-Azar in the Mediterranean region, Middle East, parts in Africa and China. Leishmania infantum: causing infantile kala-Azar in the Mediterranean region, Middle East, parts in Africa and China. Leishmania donovani: in India, East Africa and China. It is common among young adults. Leishmania donovani: in India, East Africa and China. It is common among young adults. Leishmania chagasi: in South America. It is common among children below the age of four years old. Leishmania chagasi: in South America. It is common among children below the age of four years old.

7. Morphology: 1- Amastigote: in tissue of man: Amastigote (leishmanial form) is oval and measures 2-5 microns by measures 2-5 microns by 1 - 3 microns.

8. 2- Promastigote: in the vector I.H. or culture.(NNN Medium) vector I.H. or culture.(NNN Medium) It measures 14 – 20 microns by 1.5 - 4 microns.

9. D.H. Man, dogs and rodents. The dogs and rodents are act as reservoir hosts. Vector of transmission: Female sand fly genus phlebotomus. Epidemiology: Leishmaniasis is prevalent world wide: ranging from south east Asia, Indo-Pakistan, Mediterranean, north and central Africa, and south and central America.

10. Life cycle: The Leishmania life cycle is considered a cyclopropagative life cycle (change in the form and increase in the number). Mode of infection: by a bite of infected female sand fly.

11. Pathology: Leishmania donovani is a parasite of the R.E.S. Leishmania donovani is a parasite of the R.E.S. When the promastigotes from the infected female sand fly are inoculated into the skin they are engulfed by the macrophages and change into amastigotes and start multiplication. When the promastigotes from the infected female sand fly are inoculated into the skin they are engulfed by the macrophages and change into amastigotes and start multiplication. The infected macrophages pass to the blood and all the viscera where the amastigotes invades and multiply in the R.E.S. e.g. spleen, liver, bone marrow, lymph nodes, kidney, intestine …… etc. The infected macrophages pass to the blood and all the viscera where the amastigotes invades and multiply in the R.E.S. e.g. spleen, liver, bone marrow, lymph nodes, kidney, intestine …… etc.

12. Clinical Picture: I.P varies between few weeks to few months. I.P varies between few weeks to few months. High or low grade intermittent fever. High or low grade intermittent fever. Toxemia, anorexia and loss of weight. Toxemia, anorexia and loss of weight. Hepatosplenomegaly, jaundice and disturbed liver functions (reversed A/G ratio 1:2 as the globulin increases and the albumin decreases). Hepatosplenomegaly, jaundice and disturbed liver functions (reversed A/G ratio 1:2 as the globulin increases and the albumin decreases). N.B. the normal ratio is 2:1. N.B. the normal ratio is 2:1. Anemia, leucocytopenia due to bone marrow suppression. Anemia, leucocytopenia due to bone marrow suppression.

13. Lymphadenopathy. Lymphadenopathy. Glomerulonephritis and dysentery with leishmania bodies in the urine and stool. Glomerulonephritis and dysentery with leishmania bodies in the urine and stool. Naso-pharyngeal granuloma. Naso-pharyngeal granuloma.

14. Skin: in visceral leishmaniasis, it takes 2 forms: Skin: in visceral leishmaniasis, it takes 2 forms: a- Leishmanoma: a skin nodule at the site of bite resulted from multiplication of the amastigotes in the skin macrophages. a- Leishmanoma: a skin nodule at the site of bite resulted from multiplication of the amastigotes in the skin macrophages. b- Post Kala-Azar Dermal Leishmanoid (PKDL): it is a skin condition appears after recovery and characterized by the presence of multiple depigmented macules on the exposed parts of the face and limbs. These macules change to nodules which never ulcerate. Amastigotes appear in smear from the nodules. b- Post Kala-Azar Dermal Leishmanoid (PKDL): it is a skin condition appears after recovery and characterized by the presence of multiple depigmented macules on the exposed parts of the face and limbs. These macules change to nodules which never ulcerate. Amastigotes appear in smear from the nodules. N.B. PKDL appears due to the recovery of the N.B. PKDL appears due to the recovery of the suppressed cell mediated immune response. suppressed cell mediated immune response.

16. Diagnosis: I- Clinical: Fever, hepatosplenomegaly, anemia, leucopenia and leishmanoma. II- Laboratory A. Direct diagnosis: 1- Demonstration of the organisms (amastigotes) in: Blood by blood film with thick film. Blood by blood film with thick film. Spleen by splenic puncture. Spleen by splenic puncture. Liver by liver biopsy. Liver by liver biopsy. Bone marrow by puncture biopsy. Bone marrow by puncture biopsy. 2- Culture in the NNN media: (Novy-Mc Neal and Nicolle) The PROMASTIGOTE FORM IS GROWN ON CULTURE ON NNN medium. It is formed of agar base + defibrinated rabbit blood + NaCl + Penicillin + Streptomycin. It is formed of agar base + defibrinated rabbit blood + NaCl + Penicillin + Streptomycin. 3- Animal inoculation: inoculation of the specimen in Hamster then the spleen and liver will be examined after 6 months.

17. B. Indirect diagnosis: 1- Blood examination: anemia, leucopenia and reversed A/G ratio. 1- Blood examination: anemia, leucopenia and reversed A/G ratio. 2- I.D. Test (Montenegro or Leishmanin Skin Test): the test is negative during the active infection and it turns to positive after treatment as a result of the recovery of the cell mediated immunity. 2- I.D. Test (Montenegro or Leishmanin Skin Test): the test is negative during the active infection and it turns to positive after treatment as a result of the recovery of the cell mediated immunity. 3- Formal Gel Test: 1 cc patient serum + 1 drop of commercial formalin --- it will be solid and opaque in 20 min in positive cases. 3- Formal Gel Test: 1 cc patient serum + 1 drop of commercial formalin --- it will be solid and opaque in 20 min in positive cases. 4- Urea Stibamine Test: Patient serum + 24% urea stibamine ----- white ring at the interface. 4- Urea Stibamine Test: Patient serum + 24% urea stibamine ----- white ring at the interface. 5- IFAT. 5- IFAT. 6- ELISA. 6- ELISA. 7- CFT. 7- CFT.

18. Treatment: Pentavalent antimony compounds: Pentostam 600 mg / day / 6 days IM or IV. Pentavalent antimony compounds: Pentostam 600 mg / day / 6 days IM or IV. Diamidine compounds: Pentamidine 4 mg / kg BW / 10 days. Diamidine compounds: Pentamidine 4 mg / kg BW / 10 days.Control: Treatment of patients. Treatment of patients. Control of vector. Control of vector. Destruction of reservoir hosts. Destruction of reservoir hosts.

19. Cutaneous Leishmaniasis of Old World (Oriental sore, Delhi ulcer, Baghdad boil, Allepo boil) Distribution: Mediterranean area, Sudan, Ethiopia, KSA, Iran, Iraq, India. Habitat: R.E.S found in the skin. Morphology, Vector, Life cycle inside the vector: the same as Leishmania donovani but it is only localized in the skin in a form of cutaneous ulcer.

20. Leishmania Vector Human cycle Animal reservoir vector

21. Pathology: When the promastigotes from the infected female sand fly are inoculated into the skin they are engulfed by the macrophages and change into amastigotes and start multiplication. When the promastigotes from the infected female sand fly are inoculated into the skin they are engulfed by the macrophages and change into amastigotes and start multiplication. The infected macrophages attract other macrophages, plasma cells, lymphocytes leading to a nodule formation that undergoes necrosis and ulceration. The ulcer has indurated raised edges surrounded by red area. It also contains necrotic base and sometimes secondary bacterial infection. The ulcer heals within 6-12 months. The infected macrophages attract other macrophages, plasma cells, lymphocytes leading to a nodule formation that undergoes necrosis and ulceration. The ulcer has indurated raised edges surrounded by red area. It also contains necrotic base and sometimes secondary bacterial infection. The ulcer heals within 6-12 months.

22. Clinical Types of Cutaneous Leishmaniasis: 1- Leishmania tropica (Urban, chronic, dry type): It is distributed in the Middle East, South of USSR, India and other parts of Asia. It is distributed in the Middle East, South of USSR, India and other parts of Asia. The hosts (D & R) are man and dogs (Anthroponotic). The hosts (D & R) are man and dogs (Anthroponotic). It takes a long IP (2-4 M). It takes a long IP (2-4 M). The ulcer is chronic with slow ulceration and usually it is a single dry ulcer. The parasites are present in the edges. The ulcer is chronic with slow ulceration and usually it is a single dry ulcer. The parasites are present in the edges. The lesion heals after 1-2 years. The lesion heals after 1-2 years. Immune response is cellular (ID test is positive) Immune response is cellular (ID test is positive)

23. 2- Leishmania major (Rural, acute, moist type): It is distributed in the North and Central Africa. It is distributed in the North and Central Africa. The reservoir hosts are the rodents (Zoonotic). The reservoir hosts are the rodents (Zoonotic). It takes a short IP (2-4W). It takes a short IP (2-4W). The ulcer is acute with rapid ulceration, it may be single or multiple wet ulcers with perfuse discharge. The ulcer is acute with rapid ulceration, it may be single or multiple wet ulcers with perfuse discharge. Healing is rapid as it takes 3-6 months. Healing is rapid as it takes 3-6 months. Immune response is cellular (ID test is positive). Immune response is cellular (ID test is positive).

24. Cutaneous leishmaniasis

25. 3- Leishmania aethiopica (Diffuse type): It is distributed in Ethiopia and Kenya. It is distributed in Ethiopia and Kenya. The reservoir hosts are wild rodents. The reservoir hosts are wild rodents. It is extensive as a result of the suppressed immune response. It is extensive as a result of the suppressed immune response. The ulcers are wet type. The ulcers are wet type. ID test is negative as a result of the suppressed immune response. ID test is negative as a result of the suppressed immune response.

26. Disseminated cutaneous leishmaniasis

27. 4- Leishmania recidiva (Relapsing or Lupoid type): It is distributed in the Middle East, South of USSR, India and other parts of Asia. It is distributed in the Middle East, South of USSR, India and other parts of Asia. The hosts are man and dogs (D &R). The hosts are man and dogs (D &R). It is a chronic lesion resulted from exaggerated immune response. It is a chronic lesion resulted from exaggerated immune response. The lesion starts on the face and spread gradually giving a butter fly appearance as lupus vulgaris. The lesion starts on the face and spread gradually giving a butter fly appearance as lupus vulgaris.

28. Diagnosis: I. Clinical: The ulcer may be single or multiple on the exposed area of the body. They are suspected in the patients coming from endemic areas.

29. II. Laboratory: Direct: Direct: Smear: Smear: Skin biopsy: Skin biopsy: Culture: on NNN media Culture: on NNN media PCR: PCR: Indirect: Indirect: Intradermal test.

30. Treatment: Pentavalent antimony compounds: Pentostam 600 mg / day / 6 days IM or IV or local injection. Pentavalent antimony compounds: Pentostam 600 mg / day / 6 days IM or IV or local injection. Refampicin and Metronidazole. Refampicin and Metronidazole. Cryosurgery and ulcer excision. Cryosurgery and ulcer excision.

31. Cutaneous and Mucocutaneous Leishmaniasis of New World Geographical Distribution: Central and South America. Vector: Lutozomyia. D.H.: Man. R.H.: Wild animals and rodents.

32. Leishmania mexicana: It is a cutaneous form of Leishmania and it resembles the Leishmania tropica in the pathology and the clinical picture. Leishmania mexicana: It is a cutaneous form of Leishmania and it resembles the Leishmania tropica in the pathology and the clinical picture. Leishmania braziliense: It is the mucocutaneous form of Leishmania: it starts as a skin nodule that ulcerates and extends to the mucous membrane of the nose, mouth …..etc. Leishmania braziliense: It is the mucocutaneous form of Leishmania: it starts as a skin nodule that ulcerates and extends to the mucous membrane of the nose, mouth …..etc.

33. Mcutaneous leishmaniasis

34. Diagnosis, treatment and prevention: as Leishmania tropica. Dawoud H, Linss G, judge C, Steuber S, Krueger D (1998): A case OF cutaneous leishmaniasis in A German patient in Frankfurt/Oder. Hyg. Mikrobiol. 2: 43.

35. Immunity against Leishmaniasis I. Cutaneous and Mucocutaneous Leishmaniasis: It is mainly cellular by macrophages and lymphocytes, as the macrophages engulf the invading parasites and release chemotactic substances which attract other macrophages and lymphocytes. It is mainly cellular by macrophages and lymphocytes, as the macrophages engulf the invading parasites and release chemotactic substances which attract other macrophages and lymphocytes. Humoral immune response plays a minimal role. Humoral immune response plays a minimal role.

36. The cellular immune response varies from a minimal response as in Leishmania aethiopica to exaggerated response as in Leishmania recidiva. In between the other to forms (dry and wet Leishmania tropica) exist. The cellular immune response varies from a minimal response as in Leishmania aethiopica to exaggerated response as in Leishmania recidiva. In between the other to forms (dry and wet Leishmania tropica) exist. The cellular immune response demonstrated by Montenegro skin test. The cellular immune response demonstrated by Montenegro skin test. Infection give long lasting protection as reinfection is rare but it might occur in immune suppression. Infection give long lasting protection as reinfection is rare but it might occur in immune suppression.

37. II. Visceral Leishmaniasis: The cellular immune response is suppressed during the active disease and it is reactivated after the treatment. So, Montenegro skin test is negative during the activity of the disease and it turns to positive after treatment. The cellular immune response is suppressed during the active disease and it is reactivated after the treatment. So, Montenegro skin test is negative during the activity of the disease and it turns to positive after treatment. Humoral immune response is exaggerated with production of polyclonal IgG. Humoral immune response is exaggerated with production of polyclonal IgG. Infection give long lasting immunity against reinfection. Infection give long lasting immunity against reinfection.