LeishmaniasisLeishmaniasis

Infection caused by parasite belongs Infection caused by parasite belongs to subgenus leishmania or vianniato subgenus leishmania or viannia

Its an obligate intracellular protozoaIts an obligate intracellular protozoa

Subgenus leishmania includesSubgenus leishmania includes

L.donovani complexL.donovani complex

L.donovaniL.donovani L.infantum L.infantum L.chagasiL.chagasi

L.Mexicana complexL.Mexicana complex L.mexicanaL.mexicana L.amzonensisL.amzonensis L.tropicaL.tropica L.majorL.major L.aethiopicaL.aethiopica Subgenus vianniaSubgenus viannia V.braziliensisV.braziliensis V.panamensisV.panamensis V.guanesisV.guanesis

Mode of transmissionMode of transmission

Infection transmitted by the bite of Infection transmitted by the bite of female sandflies- genus female sandflies- genus phlebotomus (old world) or phlebotomus (old world) or Lutzomyia (new world)Lutzomyia (new world)

Insect vectorsInsect vectors

Genus- phlebotomus or lutzomyia sand fliesGenus- phlebotomus or lutzomyia sand flies

Commonly found in house-hold rubbish, bark of old trees,cracks in Commonly found in house-hold rubbish, bark of old trees,cracks in wallswalls

Usually feed at night while the host asleepUsually feed at night while the host asleep

30 of 500 spp.. Of phlebotomine sand flies can transmit ds.30 of 500 spp.. Of phlebotomine sand flies can transmit ds.

Ex P.argentipes (Indian sub- continent)Ex P.argentipes (Indian sub- continent) P.oriantalis (Africa, mediterranean basin)P.oriantalis (Africa, mediterranean basin) P.chinensis&alexandri (china)P.chinensis&alexandri (china)

. .

P. Argentipes (vector for VL)P. Argentipes (vector for VL)

Life cycleLife cycle Reservoir hosts – wild and domestic animals Reservoir hosts – wild and domestic animals

such as fox,jackal,rodents and wolvessuch as fox,jackal,rodents and wolves

Domestic dogs plays imp role in harbouring Domestic dogs plays imp role in harbouring and transmitting disease to humansand transmitting disease to humans

Man – incidental hostMan – incidental host

Source of infectionSource of infection – – asymptomatic carriers asymptomatic carriers and PKDL patientsand PKDL patients

Parasite occures in two stages

Amastigote- Aflagellar stage (seen in the R.E.vertebrate host)

Promastigote-Flagellar stage( seen in gut of sandfly,Artificial culture)

1. AMASTIGOTE FORM

2.PROMASTIGOTE FORM

Life cycle of leishmaniaLife cycle of leishmania

TYPESTYPES VISCERAL LEISHMANIASISVISCERAL LEISHMANIASIS CUTANEOUS LEISHMANIASISCUTANEOUS LEISHMANIASIS MUCOSAL LEISHMANIASISMUCOSAL LEISHMANIASIS

Visceral leishmaniasisVisceral leishmaniasis Also called as kala-azar(black-fever)Also called as kala-azar(black-fever) >90% of vl occurs in Bangladesh ,India >90% of vl occurs in Bangladesh ,India

(Bihar),Nepal, Sudan and brazil.(Bihar),Nepal, Sudan and brazil. Caused by especially L. donovani complex Caused by especially L. donovani complex

transmitted by bite of female sand fly transmitted by bite of female sand fly (P.argentipes)(P.argentipes)

Ds.can also be transmitted congenitally and Ds.can also be transmitted congenitally and parenterally.parenterally.

Clinical featuresClinical features Subclinical, but can be occures in acute, Subclinical, but can be occures in acute, subacute, orsubacute, or chronic form chronic form I.P. weeks to months but can be, as long as I.P. weeks to months but can be, as long as years alsoyears also

Symptoms-Symptoms- 1.fever-highgrade,2peaks in 1.fever-highgrade,2peaks in 24hrs,ass.with24hrs,ass.with chills and rigors chills and rigors 2.drenching sweats (malaria)2.drenching sweats (malaria) 3.weight loss, poor appetite, anorexia3.weight loss, poor appetite, anorexia 4.cough,burning feet, insomnia4.cough,burning feet, insomnia 5.abdominal pain, joint pain, epistaxis,5.abdominal pain, joint pain, epistaxis, diarrhoea diarrhoea 6.neurological affects are rare 6.neurological affects are rare

signssigns

Splenomegaly (soft, non tender),can Splenomegaly (soft, non tender),can be massivebe massive

HepatomegalyHepatomegaly Peripheral lymphadenopathyPeripheral lymphadenopathy Dark skinDark skin anemiaanemia

complicationscomplications

Sec. bact.infections - Sec. bact.infections - pneumonia, dysentery, pulm.Tbpneumonia, dysentery, pulm.Tb

Rare hemolytic anemia, ARF, Rare hemolytic anemia, ARF, mucosal hemorrhagemucosal hemorrhage

Post kala-azar dermal Post kala-azar dermal leishmaniasis (PKDL)leishmaniasis (PKDL)

Usually follows recovery from kala azarUsually follows recovery from kala azar Begins with small measles like skin leisons-Begins with small measles like skin leisons-

hypopigmented macules,papuples, noduleshypopigmented macules,papuples, nodules Typically more prominent on face,eventuall Typically more prominent on face,eventuall

spread to other areas.spread to other areas. Can dev.during therapy,few moths,years Can dev.during therapy,few moths,years

later (india)later (india) Self limiting (resolving in six months)Self limiting (resolving in six months)

Cutaneous leishmaniasisCutaneous leishmaniasis

It’s a most common form of leishmaniasisIt’s a most common form of leishmaniasis >90% cases occures in afghanistan, algeria, iraq, >90% cases occures in afghanistan, algeria, iraq,

iran soudi arabiairan soudi arabia It is transmitted by P.sergenti,P.papatasiIt is transmitted by P.sergenti,P.papatasi Papule, nodules, ulcerative lesionsPapule, nodules, ulcerative lesions Resembles warts, acne, psoriasisResembles warts, acne, psoriasis Not painfulNot painful Extremities and faceExtremities and face Heal over months to years-scars-burnsHeal over months to years-scars-burns Diffuse cutaneous L. – severe formDiffuse cutaneous L. – severe form

Muco cutaneous leishmaniasisMuco cutaneous leishmaniasis(Espundia)(Espundia)

Less common Less common Most commonly caused by viannia sub Most commonly caused by viannia sub

gen. (V. brazilliensis)gen. (V. brazilliensis) Involves nose ,mouth, larynxInvolves nose ,mouth, larynx Unusual nasal symptoms- epistaxis, Unusual nasal symptoms- epistaxis,

edema, erythema of nasal mucosaedema, erythema of nasal mucosa Nodules like CL, Inside nose- perforation Nodules like CL, Inside nose- perforation

nasal septum ,enlarged lips&nose ,larynx-nasal septum ,enlarged lips&nose ,larynx-voice changevoice change

Differential diagnosisDifferential diagnosis

Includes-Includes- MalariaMalaria TyphoidTyphoid SchistosomiasisSchistosomiasis Tb, SyphilisTb, Syphilis Histoplasmosis Histoplasmosis

Diagnosis

Lab. Findings 1.pancytopenia- 2.hyper gammaglobulinemia(IgG) 3.hypo albuminemia 4.reversed albumin\globulin ratio

1. VISCERAL LEISHMANIASIS 1.clinical features but not sufficient 2.microscopic exam (amastigote form) 3.blood cultures 4.serological tests-ELISA 5.strip test-using k39 (recombinent protein)

2.CUTANEOUS & MUCOCUTANEOUS LEISHMANIASIS

staining method- Giemsa-stain(smears of dermal scrapings),

in vitro cultures (using aspirates from lymph nodes & skin lesions)

biopsy specimens for culture & PCR methods

serological tests-insensitive (AB titers low)

LEISHMANIN TEST

*+Ve in 6-8 wks after recovery*Delayed hyper sensitivity*+Ve in african kala azar, not in Indian

kala azar*-Ve in PKDL,untreated cases

TREATMENT 1. VISCERAL LEISHMANIASIS *

1.Pentavalent antimonial compounds- Inj.sodium stibogluconate (pentostam) IV\IM 20mg\kg body wt. for 28days

*Inj.pentamidine IM 2-4mg\kg body wt. for 10-15days

* Inj.Amphotericine B( preffered in India) IV 2-5mg\kg qd ( total 2-3gm) given

*Inj. paromomycine IV\IM 15-20mg\kg qd for 21days

*Miltefosine orally 50-100mg\day for 28days

*Allopurinol ORAL\IV 20mg\kg for 3days

2.CUTANEOUS LEISHMANIASIS * self healing (within 6 months)

* treatment depends on spp.and country of acquisition * Pentavalent antimonial compounds IV\IM

20mg\kg qd for 10-20days * Pentamidine IV\IM 3mg\kgfor 4 doses or

2mg\kg for 7 doses

*Amphotericine B(deoxycholate) IV 0.5-1mg\kg qd (total 20mg\kg) for 8wks

*Oral-Fuconazole 200mg qd or bd for 6wks

Ketoconazole 600mg\day 28 days Itraconazole 200mg bd for 28 days Dapsone 100mg bd for 6 wks

Local OR Topical- drugtherapy Paromomycine ointment,

methylbenzethonium chloride Intra-lesional inj. of

megutamineantimoniate Non drug therapy-local heat therapy,

cryo

3.MUCUCUTANEOUS LEISHMANIASIS

*Pentavalent antimony IV\IM 20mg\kg qd for 28 days

*Amphotericine B(deoxycholate) IV 1mg\kg qd (total 20-40mg)

*Pentamidine IV\IM 2-4mg\kg thrice\wkly for >15 doses

prognosis

*CL rarely fatal-disfiguring scars

*VL-untreated&severe cases almost fatal

*Death –organ failure,wasting synd.

*Pt.with HIV- Treat HIV, along the leishmaniasis avoid relapses.

Prevention and control

By avoiding the bite of female sandflies Insect repellents-DEET Bed-nets,cloths,and screens impregnated

with permethrin Treat human cases (L. donovani inf. in

India)

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