1. Leishmaniasis Transplant in the Tropics
First, of all I would like to thank the organizers for the invitation. Leishmaniasis in transplant setting is the topic of my talk today.
Wanessa Clemente
Digestive Transplant Service
University of Minas Gerais - Brazil

2. No conflicts of interest to disclose

3. Epidemiology
Protozoan disease transmitted through the bite of infected female sandflies
Broad range of clinical presentation
CL: single or multiple lesions, associated with multiple species
MCL: metastasis to mucosal tissues (L braziliensis)
VL: internal organs (liver, spleen and BM) - Macrophage system
In SOT presentation and response to treatment can be altered, with dissemination and visceralization of dermatotropic species
Remains a rare complication even in tropical settings
Antinori LID 2008, de Vries Am J Clin Dermatol 2015, Schwartz & Mawhorter AJT 2013, van Griesven CMI 2014.

4. Leishmania Taxonomy and Leishmaniasis Distribution
Different species are circulating worldwide
350 million people at risk
~2 million new cases/year
True prevalence: understimated
Therapy depends on Leishmania species
WHO, 2010
Kevric, Dermatol Clin 2015

5. Leishmania Taxonomy and Leishmaniasis Distribution
Visceral Leishmaniasis
Cutaneous and MC Leishmaniasis/ PKDL
General population
million/y
million/y
SOT
Several cases, % endemic area
Few cases
Greater susceptibility to VL, fewer transplants performed in highly endemic areas (CL/MCL) or publication bias.
WHO, 2010
Kevric, Dermatol Clin 2015

6. WHO 2010, Vries Am J Clin Dermatol 2015, Antinori LID 2008
Risk Factors
Exposure: outdoor activities (timber harvesting or mining, agriculture, military operations and road construction). But... Urban spread is common in some areas.
Clinical disease: parasite virulence, nutricional status, age and host genetic.
SOT: poorly studied. Disease prevalence in SOT x general population. Transplanted organ: renal recipients (bias, related to renal failure or dialysis). IS: High-dose steroids
WHO 2010, Vries Am J Clin Dermatol 2015, Antinori LID 2008

7. Reactivation or de novo infection
Acquisition
Reactivation or de novo infection
Primary infection
Reactivation of latent infection
DD transmission
Antinori, LID 2008

8. Clinical and Laboratory findings
Fever is the most common sympton
Organomegaly SOT < IC
Can be atypical and secondary infections are common
Cutaneous manifestations (before, during or after VL)
Serology: good performance
N: 79 cases, >75%: KT
Median: 18 mo after Tx. Mortality: 22%
Antinori, LID 2008

9. Diagnosis Visceral Leishmaniasis Method Direct examination Serology
Comments
Direct examination
Sensitivity: BMA 53 to 86%. Spleen: > 95%
Serology
Should be supported by clinical correlation
IFAT; ELISA; ICT; DAT
Sensitivity and specificity varies
Ag: rK39; rKLO8
Methods lack of agreement
Exposure x active infection
Cross-reaction
Molecular diagnosis
Choice of target:
rDNA – ITS-1 (identification)
kDNA
Mini-exon
Non-invasive sampling
Enable species identification
Allows monitoring, PCR + is not disease
Ag detection
Ag serum/urine, usefulness remains unclear
Ideally: combination of methods!
WHO 2010, van Griesven CMI 2014, de Vries Am J Clin Dermatol 2015

10. Older lesions  lower number of parasites
Diagnosis
Cutaneous and MC Leishmaniasis/ PKDL
Method
Comments
Direct examination
Gold-standard.
Culture
Enable species identification
Histopathology Immunohistochemical
Depends on stage, species, host response and cellular immunity.
Molecular diagnosis
Useful if parasite burden is low
Immunological and serological tests
Skin test (Montenegro)
Epidemiological studies
If DE is negative, PCR should be employed.
Older lesions  lower number of parasites
WHO 2010, de Vries Am J Clin Dermatol 2015

11. Treatment and secondary prophylaxis
Overall, decision is based on an individual basis
age
immune status
renal/liver function
Leishmania species
extend of disease
drug availability
concomitant infections
previous treatment
CL/MCL: depends also on the number and size of skin lesions. Topical treatment (cryotherapy, thermotherapy, intralesional antimonals or surgical excision) as sole therapy has not yet been reported. Systemic treatment is the preferred approach.

12. Treatment recommendations in immunosuppressed individuals
LAmb: preferred drug in different squemes
Cure rate: ~ 80% (immunocompetent patients: >90%)
Relapses episodes ≈ 30%
van Griensven, CMI, 2014 Kotton et al. AJT Schwartz et al AJT 2013

13. Is Miltefosine an option ?
Evidence-Based recommendations
Old World VL AI
Combined therapy
LAmB or
Paramomycin
L donovani BI
Alone
New World
CIII
L infantum CL
BI or CIII
Alone (28d)
Depending on species
CL, MCL
BI or BII
Alone (varies)
Mong lo & Lopéz-Vélez CID, 2015

14. Value of screening both donors and candidates
International Guidelines:
Donors: screening not recommended
Recipients: screening if previous epidemiological exposure
Serologic, skin testing or PCR
If screening is positive:
Close monitoring (clinical and laboratory)
Primary prophylaxis/ pre-emptive therapy is not recommended
Martín-Dávila P et al. Clin Microbiol Rev 2008
Schwartz B et al. Am J Transplant 2013
Johan van Griensven, et al. Clin Microbiol Infect 2014

15. Screening limitations
VL screening in LT recipients and donors
Laboratory test
LT Recipients
(N = 50)
Matched-Liver Donors (N = 17)
Positive IFA (≥ 1:80)
1 (2%)
Anti-Leish rK39 rapid test
Any PCR detection
4 (8%)
4 (23.5%)
Blood 1 4
Liver 3
Spleen NA
None of the LT recipients developed VL over 24 mo follow-up
Clemente et al, AJT 2014.
No concordance between serology and PCR
Serology should not be used for screening because of the lack of sensitivity
PCR presented higher sensitivity and specificity, but the role of PCR pre-tx needs to be determined
3 VL cases ~ 830 LT; 2% asymptomatic infection
Persistence of parasite in tissue after treatment does not necessarily represent development to relapse.
Silva LA et al. Rev Inst Med Trop São Paulo 2013
Moreno EC et al. PloS Negl Trop Dis 2009

16. Worldwide asymptomatic carriers of L infantum
Up to 70% depending on the method and studied endemic area
Michel, Acta Tropica 2011

17. Exposure prevention
When visiting endemic areas, minimize outdoors ativities (especially during late afternoon)
Protective clothing
Insect repellent
Bed nets
Ahead of print. Recommendations on Travel Medicine and Management of Endemic Diseases in SOT recipients: Latin America

18. Case Presentation – Visceral Leishmaniasis
17 yo male, LT due to Autoimmune cirrhosis (3 y before) IS regimen: Steroid + FK.
Admission: 3 months: weight loss (3kg), bloody diarrhea, visceromegaly, but no fever. Pancytopenia (Hg 8.1g/dL; WBC 1,300/mm3; Platelets 79,000/ mm3). Negative Anti-Leishmania serology IFAT
Colonoscopy: Gross nodularity hyperemia and friability. Intestinal biopsy and Bone Marrow aspirate: Leishmania amastigotes. COLONIC LEISHMANIASIS
Treatment: LamB 3 mg for 7 days. Resolution of diarrhea, weight gain and spleen size normalization. Normal blood count.
Relapse 5 mo after treatment. Mantained with secondary prophylaxis 3 mg/kg/monthly (18 months)
Araujo et al Am J Trop Med Hyg 2010
Clemente et al Transplantation 2011

19. No previous symptomatic infection or treatment
Visceral Leishmaniasis after SOT Multicenter study, ( 10 Spanish and 2 Brazilian centers)
36 VL cases:/ Tx (0.1%)
Treatment option %
Amphotericin B
83%
Days of LamB
10 d
Secondary prophylaxis after cure
34%
75%
Relapse after cure
26%
With NO secondary prophylaxis
35%
With secondary prophylaxis 8%
Mortality at 30 days
2.8%
5.7 fold more frequent in Brazil compared to Spain
Brazil - ~ 2 cases/ 100,000 (0.5%)
Spain cases/100,000 (0.1%)
Median time post-transplant
11 months
Clinical manifestations
Temperature > 38ºC
86%
Visceromegaly
81%
Cytopenia
47%
Diagnostic methods
Bone marrow microscopy
PCR
75%
Culture
59%
Serology (IFA + rK39)
76%
No previous symptomatic infection or treatment
Clemente et al REIPI Network. CMI 2015 19

20. Case Presentation – Simultaneous Mucosal and Cutaneous Leishmaniasis
67 yo woman from Igassu falls (endemic), living in Curitiba/BR
One-year post-KT:
Edema in nose, nasal obstruction and persistent rhinorrhea
2 cutaneous lesions (2 wk before admission)
Lesions biopsies:
Amastigotes
Positive culture
Positive PCR: Leishmania (Viannia) braziliensis.
Treated with LamB 3 mg/kg/day with improvement after 14 days
SOT: Self-limiting lesion to severe anddisfiguring lesions. Atypical features include dissemination polymorphism and visceralization
Tuon et al. Am J Trop Med Hyg 2014.

21. Leishmaniasis Distribution in Latin America
MCL: L braziliensis and L panamensis
CL: L amazonensis
VL: L infantum ~ L chagasi

22. Summary: Leishmaniasis in SOT
Is an unusual disease (even in endemic areas), the frequency varies according to prevalence in the GP. Occur any time after transplantation, mostly during the first year. Endemicity can be related to early disease. VL most common manifestations: fever, spleen enlargement and pancytopenia. Only one-third of the patients exhibited this classical triad (Clemente et al, CMI 2015) Diagnosis: combination of different methods (microscopy, serology, culture and PCR) is the best approach. The current recommendation of recipient screening should be reconsidered. The preferred therapy is LAmB. Secondary prophylaxis after treatment may reduce the risk of relapse. Mortality rate: ~30, if not promptly recognized and treated.
Antinori et al., LID 2008, de Vries Am J Clin Dermatol 2015, Schwartz & Mawhorter AJT 2013, van Griesven CMI 2014