Varied collection of protozoal diseases Named after Leishman - First identified the

organisms in 1901 Smears taken from a man who had died of

“Dum Dum” fever Annually - Two million cases worldwide Has emerged as an AIDS - associated

opportunistic infection

1. Cutaneous

2. Diffuse cutaneous

3. Mucocutaneous

4. Visceral Leishmaniasis (Kala Azar)

Endemic in 88 countries on five continents Cutaneous Leishmaniasis cases occur in Iran,

Afghanistan, Syria, Saudi Arabia, Brazil and Peru

Visceral Leishmaniasis cases occur in Bangladesh, Brazil, India and Sudan

World Health Organization estimates that 350 million people are at risk

2.4 million disability - adjusted life years

Around 7,00,000 deaths per year

WHO South East Asia Region - 200 million

people in the Region are “at risk”

World’s largest foci of Visceral Leishmaniasis, accounting for 50% of the total burden

Endemic in 4 states in India: Bihar- 32 districts Jharkhand- 4 districts West Bengal- 11 districts Uttar Pradesh- 5

districts

An estimated 165.4 million population is at risk About 1,00,000 cases occur annually

19 protozoan species Genus Leishmania Amastigote- obligate intracellular parasites

and divide in macrophages- diagnostic phase

Promastigotes- extracellular present in the arthropod vectors- infective phase

Absence of cross immunity

Leishmania donovani complex Leishmania donovani, L. infantum and L.

chagasi Leishmania mexicana complex

L. mexicana, L. amazonensis and L. venezuelensis

Leishmania tropica Leishmania major Leishmania aethiopica In India: Leishmania donovani

Female sand flies of the genus Lutzomyia in the Americas and Phlebotomus in other parts of the world

Sandflies breed in cracks and crevices in the soil and buildings, tree holes and caves

Sandflies are active in the evening and night - time hours

In India, Phlebotomus argentipes is a proven vector of KalaAzar.

Cutaneous form mainly zoonotic, - humans are accidentally exposed

Indian Kala - Azar is anthroponotic with humans being the only known reservoir of infection

Peak age of infection is 5 to 9 years Males Poor socio-economic background Common in various farming practices,

forestry, mining and fishing

Mostly confined to the plainsOvercrowding,Poor ventilationHigh relative humidity, warm temperatureAccumulation of organic matter in the

environment facilitates transmission

Transmitted by the bite of infected female sandflies

Rarely: initiated by amastigotes via blood (shared needles, transfusion, transplacental spread) or organ transplantation

Incubation period: Extremely variable (10 days - 3 to 8

months – 2 yrs)Varied presentation:

Ulcerative skin lesions Destructive mucosal inflammation Disseminated visceral infection

Typical lesion : Develops at the site where

promastigotes are injected by the vector A papule - papule enlarges – ulcerates

Multiple lesions may be present

Infected with Leishmania braziliensis Begins with nasal stuffiness and

inflammation Ulceration of the nasal mucosa and

septum follows. The lips, cheeks, soft palate, pharynx

and larynx may eventually be involved, resulting in substantial disfigurement

More common among immunosuppressed with neoplasms or AIDS

Recurrent fever Loss of appetite, pallor and weight loss with

progressive emaciation Weakness Splenomegaly - spleen enlarges rapidly to

massive enlargement, usually soft and non-tender

Liver - enlargement not to the extent of spleen, soft, smooth surface, sharp edge

Death often occurs due to a secondary bacterial infection, such as

Pneumonia, Septicemia, Dysentery, Tuberculosis, Measles Other viral infections

Anaemia, Neutropenia, Thrombocytopenia and pronounced hypergammaglobulinemia.

The anaemia is usually normocytic, normochromic, unless there is concomitant iron deficiency

Leukopenia can be profound with white blood cell counts below 1000/mL

The globulin level can reach 9 or 10 g/dl.

Some patients in India and Africa develop skin lesions following treatment, ranging from hyperpigmented macules to frank nodules

Skin lesions typically appear 1 or 2 years after treatment and may persist for as long as 20 years.

Persistence of lesions beyond one year is associated with high anti - leishmanial antibody titers and negative leishmanial skin test responses

Anti - leishmanial treatment is indicated in Indian PKDL

Immunocompromised individuals progress to develop the disease far more often than immunocompetent people

It quickly accelerates the onset of AIDS and shortens the life expectancy of HIV - infected people.

Visceral Leishmaniasis is considered a major contributor to a fatal outcome HIV in co - infected patients

Parasite Identification: Wright-Giemsa stain is used for identifying

amastigotes in tissue sections Serology:

Anti-leishmanial antibody titers are typically present in:▪ High titer in people with Visceral Leishmaniasis

and ▪ Low titer or undetectable in those with

Cutaneous Leishmaniasis. Assays such as ELISA, IFAT and agglutination

assays, rk-39 rapid diagnostic test

Skin Test Intradermal leishmanin (Montenegro)

skin test Positive Negative

- Asymptomatic- Self resolving leishmania- Following successful treatment

- Progressive visceral Leishmaniasis- Diffuse cutaneous Leishmaniasis

Aldehyde test Napier is a simple test 1 to 2 ml of serum from a case of kala-

azar is taken and a drop or two of 40 per cent formalin is added. A positive test is indicated by jellification to milk- white opacity like the white of a hard-boiled egg so that in ordinary light newsprint is invisible through it

FIRST LINE OF DRUGS

SHORT TERM LONG TERM

SSG SENSITIVITY >90%

SSG SENSITIVITY <90%

SSG 20 mg/Kg i.m or i.v for 20 days

Amphotericin B 1mg/kg i.v daily or alternate days

SSG RESISTANCE >20%

SSG SENSITIVITY >80%

MILTEFOSINE 100mg/day divided doses for 4 weeks

SSG 20mg/kg/ day i.m/i.v for 30 days

CONTROL OF RESERVOIR

SECOND LINE OF DRUGS

SSG FAILURE SSG AND MILTEFOSINE FAILURE

Amphotericin B 1mg/kg i.v daily or alternate

LIPOSOMAL AMPHOTERICIN B

Treatment of PKDL : SSG in usual dosage for kala azar Could be given for 120 days. Repeated 3-4 courses of Amphotericin B

can be given in patients failing SSG treatment.

Sandfly Control: using residual insecticides, DDT used as the first choice BHC may be used as second line of defence Santation measures like removal of breeding

places

Personal prophylaxis: The short - term visitor to an endemic area should use personal protective measures to avoid sand fly bites

The application of DEET (diethyltoluamide) Use of fine mesh nets Application of insect repellants

1. The disease is endemic in following three countries of the WHO South East Asia Region except: (a). Bangladesh (b) India (c) Nepal (d) Sri lanka

2. The disease is reported in _________ no of districts in India:(a) 51 (b) 52 (c) 53 (d) 54

3. State which accounts for more than 90 per cent of the cases in India (a) Uttar Pradesh (b) Bihar (c) Assam (d) M.P

4. Leishmania donovani complex comprises of all except (a) Leishmania infantum (b) Leishmania chagasi (c) Leishmania venezuelensis (d) Leishmania donovani5. Cutaneous Leishmaniasis is also known as all the following except (a) Oriental sore (b) Aleppo evil (c) Delhi boil (d) EspundiaAnswers : (1) d; (2) b; (3) b; (4) c; (5) a.