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Leishmaniasis

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<ul><li>Infection caused by parasite belongs to subgenus leishmania or viannia </li></ul><ul><li>Its an obligate intracellular protozoa </li></ul>

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<ul><li>Subgenus leishmania includes </li></ul><ul><li>L.donovani complex </li></ul><ul><li>L.donovani </li></ul><ul><li>L.infantum </li></ul><ul><li>L.chagasi </li></ul><ul><li>L.Mexicana complex </li></ul><ul><li>L.mexicana </li></ul><ul><li>L.amzonensis </li></ul><ul><li>L.tropica </li></ul><ul><li>L.major </li></ul><ul><li>L.aethiopica </li></ul><ul><li>Subgenus viannia </li></ul><ul><li>V.braziliensis </li></ul><ul><li>V.panamensis </li></ul><ul><li>V.guanesis </li></ul>

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<ul><li>Mode of transmission </li></ul><ul><li>Infection transmitted by the bite of female sandflies- genus phlebotomus (old world) or Lutzomyia (new world) </li></ul>

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<ul><li>Insect vectors </li></ul><ul><li>Genus- phlebotomus or lutzomyia sand flies </li></ul><ul><li>Commonly found in house-hold rubbish, bark of old trees,cracks in walls </li></ul><ul><li>Usually feed at night while the host asleep </li></ul><ul><li>30 of 500 spp.. Of phlebotomine sand flies can transmit ds. </li></ul><ul><li>Ex P.argentipes (Indian sub- continent) </li></ul><ul><li>P.oriantalis (Africa, mediterranean basin) </li></ul><ul><li>P.chinensis&alexandri (china) </li></ul><ul><li>. </li></ul>

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P. Argentipes (vector for VL)

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Life cycle <ul><li>Reservoir hosts – wild and domestic animals such as fox,jackal,rodents and wolves </li></ul><ul><li>Domestic dogs plays imp role in harbouring and transmitting disease to humans </li></ul><ul><li>Man – incidental host </li></ul><ul><li>Source of infection – asymptomatic carriers and PKDL patients </li></ul>

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<ul><li>Parasite occures in two stages </li></ul><ul><li>Amastigote- Aflagellar stage (seen in the R.E.vertebrate host) </li></ul><ul><li>Promastigote-Flagellar stage( seen in gut of sandfly,Artificial culture) </li></ul>

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<ul><li>1. AMASTIGOTE FORM </li></ul><ul><li>2.PROMASTIGOTE FORM </li></ul>

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Life cycle of leishmania

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<ul><li>TYPES </li></ul><ul><li>VISCERAL LEISHMANIASIS </li></ul><ul><li>CUTANEOUS LEISHMANIASIS </li></ul><ul><li>MUCOSAL LEISHMANIASIS </li></ul>

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<ul><li>Visceral leishmaniasis </li></ul><ul><li>Also called as kala-azar(black-fever) </li></ul><ul><li>>90% of vl occurs in Bangladesh ,India (Bihar),Nepal, Sudan and brazil. </li></ul><ul><li>Caused by especially L. donovani complex transmitted by bite of female sand fly (P.argentipes) </li></ul><ul><li>Ds.can also be transmitted congenitally and parenterally. </li></ul>

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<ul><li>Clinical features </li></ul>Subclinical, but can be occures in acute, subacute, or chronic form I.P. weeks to months but can be, as long as years also Symptoms- 1.fever-highgrade,2peaks in 24hrs,ass.with chills and rigors 2.drenching sweats (malaria) 3.weight loss, poor appetite, anorexia 4.cough,burning feet, insomnia 5.abdominal pain, joint pain, epistaxis, diarrhoea 6.neurological affects are rare

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signs <ul><li>Splenomegaly (soft, non tender),can be massive </li></ul><ul><li>Hepatomegaly </li></ul><ul><li>Peripheral lymphadenopathy </li></ul><ul><li>Dark skin </li></ul><ul><li>anemia </li></ul>

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complications <ul><li>Sec. bact.infections - pneumonia, dysentery, pulm.Tb </li></ul><ul><li>Rare hemolytic anemia, ARF, mucosal hemorrhage </li></ul>

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Post kala-azar dermal leishmaniasis (PKDL) <ul><li>Usually follows recovery from kala azar </li></ul><ul><li>Begins with small measles like skin leisons- </li></ul><ul><li>hypopigmented macules,papuples, nodules </li></ul><ul><li>Typically more prominent on face,eventuall spread to other areas. </li></ul><ul><li>Can dev.during therapy,few moths,years later (india) </li></ul><ul><li>Self limiting (resolving in six months) </li></ul>

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Cutaneous leishmaniasis <ul><li>It’s a most common form of leishmaniasis </li></ul><ul><li>>90% cases occures in afghanistan, algeria, iraq, iran soudi arabia </li></ul><ul><li>It is transmitted by P.sergenti,P.papatasi </li></ul><ul><li>Papule, nodules, ulcerative lesions </li></ul><ul><li>Resembles warts, acne, psoriasis </li></ul><ul><li>Not painful </li></ul><ul><li>Extremities and face </li></ul><ul><li>Heal over months to years-scars-burns </li></ul><ul><li>Diffuse cutaneous L. – severe form </li></ul>

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Muco cutaneous leishmaniasis (Espundia) <ul><li>Less common </li></ul><ul><li>Most commonly caused by viannia sub gen. (V. brazilliensis) </li></ul><ul><li>Involves nose ,mouth, larynx </li></ul><ul><li>Unusual nasal symptoms- epistaxis, edema, erythema of nasal mucosa </li></ul><ul><li>Nodules like CL, Inside nose- perforation nasal septum ,enlarged lips&nose ,larynx-voice change </li></ul>

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Differential diagnosis <ul><li>Includes- </li></ul><ul><li>Malaria </li></ul><ul><li>Typhoid </li></ul><ul><li>Schistosomiasis </li></ul><ul><li>Tb, Syphilis </li></ul><ul><li>Histoplasmosis </li></ul>

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Diagnosis <ul><li>Lab. Findings </li></ul><ul><li>1.pancytopenia- </li></ul><ul><li>2.hyper gammaglobulinemia(IgG) </li></ul><ul><li>3.hypo albuminemia </li></ul><ul><li>4.reversed albuminlobulin ratio </li></ul>

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

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<ul><li>2.CUTANEOUS & MUCOCUTANEOUS LEISHMANIASIS </li></ul><ul><li>staining method- Giemsa-stain(smears of dermal scrapings), </li></ul><ul><li>in vitro cultures (using aspirates from lymph nodes & skin lesions) </li></ul><ul><li>biopsy specimens for culture & PCR methods </li></ul><ul><li>serological tests-insensitive (AB titers low) </li></ul>

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<ul><li>LEISHMANIN TEST </li></ul><ul><li>*+ Ve in 6-8 wks after recovery </li></ul><ul><li>* Delayed hyper sensitivity </li></ul><ul><li>*+ Ve in african kala azar, not in Indian kala azar </li></ul><ul><li>*- Ve in PKDL,untreated cases </li></ul>

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TREATMENT <ul><li>1. VISCERAL LEISHMANIASIS </li></ul><ul><li>* 1.Pentavalent antimonial compounds- </li></ul><ul><li>Inj.sodium stibogluconate (pentostam) </li></ul><ul><li>IVM 20mgg body wt. for 28days </li></ul><ul><li>*Inj.pentamidine IM 2-4mgg body </li></ul><ul><li>wt. for 10-15days </li></ul><ul><li>* Inj.Amphotericine B( preffered in India) IV </li></ul><ul><li>2-5mgg qd ( total 2-3gm) given </li></ul>

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<ul><li>*Inj. paromomycine IVM 15-20mgg qd for 21days </li></ul><ul><li>*Miltefosine orally 50-100mgay for 28days </li></ul><ul><li>*Allopurinol ORALV 20mgg for 3days </li></ul>

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<ul><li>2.CUTANEOUS LEISHMANIASIS </li></ul><ul><li>* self healing (within 6 months) </li></ul><ul><li>* treatment depends on spp.and country </li></ul><ul><li>of acquisition </li></ul><ul><li>* Pentavalent antimonial compounds IVM </li></ul><ul><li>20mgg qd for 10-20days </li></ul><ul><li>* Pentamidine IVM 3mggfor 4 doses or 2mgg for 7 doses </li></ul>

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<ul><li>* Amphotericine B(deoxycholate) IV 0.5-1mgg qd (total 20mgg) for 8wks </li></ul><ul><li>* Oral-Fuconazole 200mg qd or bd for 6wks </li></ul><ul><li>Ketoconazole 600mgay 28 days </li></ul><ul><li>Itraconazole 200mg bd for 28 days </li></ul><ul><li>Dapsone 100mg bd for 6 wks </li></ul>

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<ul><li>Local OR Topical- drugtherapy </li></ul><ul><li>Paromomycine ointment, methylbenzethonium chloride </li></ul><ul><li>Intra-lesional inj. of megutamineantimoniate </li></ul><ul><li>Non drug therapy-local heat therapy, cryo </li></ul>

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<ul><li>3.MUCUCUTANEOUS LEISHMANIASIS </li></ul><ul><li>* Pentavalent antimony IVM 20mgg qd for 28 days </li></ul><ul><li>* Amphotericine B(deoxycholate) IV 1mgg qd (total 20-40mg) </li></ul><ul><li>* Pentamidine IVM 2-4mgg thricekly for >15 doses </li></ul>

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prognosis <ul><li>* CL rarely fatal-disfiguring scars </li></ul><ul><li>* VL-untreated&severe cases almost fatal </li></ul><ul><li>* Death –organ failure,wasting synd. </li></ul><ul><li>* Pt.with HIV- Treat HIV, along the leishmaniasis avoid relapses. </li></ul>

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Prevention and control <ul><li>By avoiding the bite of female sandflies </li></ul><ul><li>Insect repellents-DEET </li></ul><ul><li>Bed-nets,cloths,and screens impregnated with permethrin </li></ul><ul><li>Treat human cases (L. donovani inf. in India) </li></ul>

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