The lesion generally commences as a small papulopustular swelling of the skin localised in the region of nostrils, mouth or eyes or widespread on the face, ears, elbows and knees. After a variable period of time the Mucosal surface of the mouth and nose are involved causing destructive and mutilating erosions. Some time the whole of the nasal septum are involved. Nasal mucous membrane, pharynx, larynx and upper lips are involved. Sometimes whole of the nasal septum is destroyed. Granulomas develop at mucocutaneous junction followed by gross destruction of soft tissue and cartilage causing disfigurement of nose and mouth. Death may occur from severe respiratory infection due to respiratory acute obstruction.
A classical lesion shows a nodule at the site of inoculation followed by a formation of a central crust. The crust may fall away exposing a wet type of ulcer. A depressed scar and altered pigment develops on healing of that nodule at the edge of lesion are characteristic features. Or CL may be presented with papulonodular lesion covered by sperficial scales(dry type of ulcer). Whole of the nasal septum is destroyed producing the typical tapir or camel nose. Nasal mucous membrane, pharynx, larynx and upper lips are involved. Sometimes whole of the nasal septum is destroyed. Granulomas develop at mucocutaneous junction followed by gross destruction of soft tissue and cartilage causing disfigurement of nose and mouth. Death may occur from severe respiratory infection due to respiratory acute obstruction.
Profile view of a teenage boy suffering from visceral leishmaniasis. The boy exhibits splenomegaly, distended abdomen and severe muscle wasting. Pyrexia: Must say One of the early symptom Splenic enlargement: One of the most striking features
The lesion commences as a papulopustular swelling of the skin localised in the region of nostrils, mouth or eyes or widespread on the face, ears, elbows and knees. After a variable time the mucosal surface of the mouth and nose are involved causing destructive and mutilating erosions. Sometimes the whole of nasal septum is destroyed.
Amastigote stage is present in man only Promastigote stage is present in Sandflies as well as cultures.
The cells of the R.E. system of the affected organs proliferate and become heavily parasitised, accompained by an increase in the IgG fraction of the serum gamma globulin(hypergammaglobulinaemia) which however is not protective. The increase in gamma globulin causes a reversal of albumin-globulin ration.
In variably cause infection once bite any susceptible person
Must talk of Leishmanin tests.
Drawback with the culture: Slow and takes a long time(about one month) L.Donovani can be cultured in a medium composed of two parts of salt agar and one part of defibrinated rabbit’s blood. The medium was first introduced by Novy, MacNeal and later modified by Nicolle.
Average total count is 3000 to 7-8000 per mm3 and there is progressive diminution during the course of the disease, the count falling to 1000 per mm3. Must talk about drawback of Aldehyde test. There is a reversal of albumin:globulin ratio
Dr. sanjay s negi leishmaniasis
DR. SANJAY SINGH NEGI
ASSISTANT PROFESSOR, DEPARTMENT OF MICROBIOLOGY, AIIMS, RAIPUR
kala azar, black fever, sandfly disease,
Dum-Dum fever and espundia.
1903 – Sir William Leishman discovered L.
donovani in spleen smears of a soldier who died
of fever at Dum-Dum, India. The disease was
known locally as Dum-Dum fever or kala-azar.
1903 – Charles Donovan found same parasite
in a spleen biopsy.
•Cultured by Rogers(1904)
•Amastigote and promastigote forms were
described by Batton(1907)
•Phlebotomus argentipes identified as vector.
• Transmitted to the mammalian hosts by the bite of
infected sandflies, Phlebotomus and Lutzomyia
In India: Phlebotomus argentipus
• Currently, leishmaniasis occurs in 4 continents and is
considered to be endemic in 88 countries, 72 of which are
90% of all VL: Bangladesh, Brazil, India, Nepal and
90% of all MCL: Bolivia, Brazil and Peru
90% of all CL : Afghanistan, Brazil, Iran, Peru, Saudi
Arabia and Syria, India(Central & Western India)
• Annual incidence: 1- 1.5 million cases of CL
: 500,000 cases of VL
• Prevalence: 12 million people
• Population at risk: 350 million
SITUATION IN INDIA
40-50% of global burden
(Bora 1999, Natl Med J India)
INDIA: 15538 cases and 47
deaths by VL (2010)
Endemic states in Eastern
India: Bihar, Jharkhand, West
Bengal, Assam, Orissa, Tamil
Nadu, Uttar Pradesh
Surveillance being done by
Estimated 165.4 million
population at risk in 4 states
procyclics and metacyclics
• Infected macrophages are
taken up with the blood
meal and amastigotes are
released by digestion,
transform into procyclic
promastigotes and attach to
the midgut epithelium
• Attached promastigotes
divide rapidly (procyclics
are not infective to
• Metacyclic (infective)
replication, detach and pass
forward into the pharynx
from where they are
regurgitated into the bite
TYPES OF LEISMANIASIS
• VISCERAL LEISHMANIASIS or Kala-azar ( Middle east,
Africa, Bangladesh, Brazil, India,China, South America, Europe,
Nepal and Sudan)
Post kala azar dermal leishmaniasis (Endemic to India and the
• India(Bihar, West bengal, Orissa, Assam, Tamil Nadu, Gujarat,
Punjab & Jammu)
• Species responsible: L.donovani
• Vector: P.argentipes
• Resvoir: Man
Other species causing Visceral Leishmaniasis
Leishmania infantum: Cause Zoonotic visceral leishmaniasis
(ZVL) in Mediterranean areas, Middle east, and China
Reservoir: Dogs, foxes and jackals
Leishmania chagasi: Zoonotic visceral leishmaniasis(ZVL) in
Reservoir: Dogs and foxes
Pathogenicity of Leishmania donovani(Visceral
Weeks to months incubation period.
May exceed one and sometimes two years.
High fever. Fever often oscillates with a
peak every second day
The lead symptom is abdominal swelling
due to hepato- and splenomegaly
Progressive drastic weight loss (kachexia).
In fully developed cases, emaciation and
anaemia become noticeable.
Darkening of the skin
Mortality of untreated disease 75-95%
• Enlarged spleen and liver in an autopsy of an
infant dying of visceral leishmaniasis.
Post Kala Azar Dermal Leishmaniasis
Non ulcerative cutaneous lesion prevalent in
endemic areas of kala azar in India.
In 10 % treated cases of Kala azar, Normally
develops <2 years after recovery(When Visceral
infection disappears but skin infection persists).
Depigmented macules: earliest lesion, trunk,
extremities and face
Erythematous patches: Nose, cheeks and chin
Yellowish pink nodules: Nodules mostly on face
& are soft, painless granulomatous growth of
varying sizes(Absences of ulceration is a
Do not heal spontaneously.
Restricted to skin
A very resistant case
cured after long
CUTANEOUS LEISHMANIASIS (Oriental Sore /Old World
Cutaneous Leishmaniasis PKDL):
(Middle east, Mediterranean areas, N.Africa, N.W. India and Pakistan)
Cause dry type of cutaneous lesion(non-ulcerating type)
Incubation period (2 months to > year)
Lesion usually facial. Ulcer starts as small itching papule covered with
fine whitish scale which subsequently becomes thick, dark and finally
falls off. The lesion may be found on the face, feet, legs and arms.
Children are usually affected.
Reservoir: man, domestic dog
VL in exceptional cases
Species: Leismania tropica
Leishmania major: Cause a moist type local cutaneous lesion(Ulcerating
Ulcer found on extremities with regional lymphadenitis. Incubation period
Leishmania tropica (Cutaneous Leishmaniasis or Oriental Sore or
Life Cycle: Same as L.donovani except
mononuclear cells of the skin and not in the
Clinical features: Cutaneous lesion begins
as a raised nodule, its ulcerates, heal
spontaneously taking about 6 months or
more by Ulcer filled up by granaluation
tissues and a depressed white scar is often
Smear made from specimen obtained by
puncture of indurated edges of the sore and
stained by Leishman method.
Oriental Sore on the face)
DIFFUSE CUTANEOUS LEISHMANIASIS / MUCO
CUTANEOUS LEISHMANIASIS / New world Cutaneous
Leishmaniasis OR ESPUNDIA
Geographical Distribution: Central and South America
(Bolivia, Brazil,Argentina, Columbia,Mexico, panama,
Paraguay, Venezuela and Peru.
Species: Leishmania braziliensis
Clinical feature: Two stages primary cutaneous lesion
followed by secondary mucosal involvement which occurs
after a variable time of latency of primary cutaneous lesion
Nasal mucous membrane, pharynx, larynx & upper lip are
and throat cavities
Develops in 5 % patients suffering from primary cutaneous lesion.
Diagnosis by demonstrating amastigote forms of L.brazilensis in skin
and mucocutaneous lesions
or LD bodies). Lying
in macrophage cells
from liver. Giemsa.
×12000. Enlarged by
• A macrophage
• Amastigotes (*)
donovani in the
cells of a spleen.
µm in diameter.
Susceptible Animal: Dog naturally infected with L.donovani
Common laboratory animals mice, rats and guinea pigs not
Hamster very susceptible.
Leishmania infects and thrives in
Macrophages are important
“microbe killers”, however
several pathogens have found
ways to escape killing
Trypansoma cruzi -- induces
phagocytosis but then escapes
into the cytoplasm
Toxoplasma -- active invasion,
parasitophorous vacuole is
never part of the endocytic
Mycobacterium tuberculosis -induce phagocytosis and block
Leishmania parasites exist Amastigote & Pro
The parasite lives in the
digestive tract of sandflies as
1. Leishmaniasis is transmitted by the bite of female
phlebotomine sandflies. The sandflies inject the
infective stage, promastigotes, during blood meals.
2. Promastigotes that reach the puncture wound are
phagocytized by macrophages.
3.They transform into amastigotes.
4. Amastigotes multiply in infected cells and affect
5. Sandflies become infected during blood meals on
an infected host when they ingest macrophages
infected with amastigotes.
6. In the sandfly's midgut, the parasites differentiate
7. They multiply and migrate to the proboscis.
Other method of transmission
Congenital infection of a child in utero
Transmission by blood transfusion
Transmission by inoculation of cultures of L.donovani
Possibly transmission during coitus.
Demonstration of Leishmania
Specimens that may be collected
• Splenic aspirate and biopsy
• Bone marrow (Sternum or iliac crest)
• Blood buffy coat
• Liver biopsy
• FNAC and biopsy
• Tegumantary leishmaniasis- dermal scrapings, sections
from skin biopsy
DEMONSTRATION OF Leishmania
AMASTIGOTES/ L.D. BODIES
Culture media for axenic culture
• SOLID MEDIUM
NNN medium (Novy, MacNeal & Nicolle)
(2ml of patient blood + 10ml of Citrated saline kept at 22 0 C
overnight and deposit inoculated into the water of
condensation of NNN medium and incubated at 220 C for
1 to 4 wks
Evan’s modified Tobie’s medium
• LIQUID MEDIA
Schneider’s Drosophila medium
Grace’s insect tissue culture medium
DEMONSTRATION OF Leishmania PROMASTIGOTES
• Golden hamsters inoculated intraperitoneally
Promastigotes as seen in artificial culture medium
IMMUNOLOGICAL METHODS (Indirect Evidence)
• Leishmanin test: 0.1 to 0.2 ml of a suspension(having 6 to 10 million
promastigotes/ml) injected intradermally. Positive reaction after 72
hours in cured kala azar cases 6 to 8 wks after recovery.
• Blood Count: Leucopenia(Neutropenia)
• Aldehyde (formol gel) Test (Napier)(To test the rise of gamma globulin):
1 to 2 ml of a serum + one or two drop of 40% formalin: Jellification of
milk white opacity
• Complement fixation test with W.K.K Ag.(Not used nowadays).
• Other Serological tests: CIEP, IHA, IFA(Most Commonly Used), ELISA,
Direct agglutination test and Latex particle agglutination test)
Detection of anti-leishmanial
antibody using fixed promastigotes
Demonstrated in the very early
stages of infection and
undetectable six to nine months
Titers >1:20 are significant and
above 1:128 are diagnostic
Cross reaction with trypanosomal
sera (overcome by
using Leishmania amastigotes as
the antigen instead of the
Direct Agglutination Test
Use of whole, stained
promastigotes either as a
suspension or in a freeze-dried
The freeze-dried form is heat
Utilized for field purposes
Relative long incubation time
of 18 hours
Need for serial dilutions of
No prognostic value
Remain positive for several
years after cure
Modifications of DAT
• Fast Agglutination Screening Test
(Schoone et al, 2001)
Need of only 1 serum dilution
Rapid: results available in less than 3 hours
• EasyDAT method
(Gomez-Ochoa et al, 2003, Clin Diagn Lab Immunol)
Many antigens have been explored for the diagnosis of
• Whole soluble antigens (Ld-ESM—Excretory, secretory
and metabolic antigen by L.donovani)
• Purified antigens such as fucose- mannose
• Defined, synthetic peptides
• Recombinant antigens
rGBP (L.major protein encoding a hydrophilic protein)
rORFF (L. infantum)
• Rapid dipstick test
• Based on the recombinant k39 protein, a 39-amino acid
cloned in Escherichia coli, from the C terminus of the
kinesin protein of Leishmania major in India
GOAL OF NATIONAL HEALTH POLICY
ELIMINATION OF KALA AZAR
• SODIUM ANTIMONY COMPOUND: SODIUM ANTIMONY
GLUCONATE(SAG 600mg daily for 6-10 days IV route)
• PENTAMIDINE ISTHIONATE
• Phase III Trials with a first-generation vaccine (killed
Leishmania organism mixed with a low concentration of
BCG as an adjuvant) have also yielded promising results
Leishmania major mixed with BCG have been successful
in preventing infection with Leishmania donovani.
• Suppress the reservoir: dogs, rats, gerbils, other small
mammals and rodents
• Suppress the vector: Sandfly
• Critical to preventing disease in stationary troop populations
• Prevent sandfly bites: Personal Protective Measures
Most important at night
Insect repellent w/ DEET
Permethrin treated uniforms
Permethrin treated bed nets