Leishmaniasis is a parasitic disease transmitted through sandfly bites that causes three main forms: cutaneous (skin lesions), visceral (liver, spleen, bone marrow), and mucocutaneous (mouth, nose). It is endemic in 88 countries, infecting 12 million people annually. In the Middle East, L. major causes cutaneous disease while L. tropica causes cutaneous and sometimes visceral disease. Diagnosis requires biopsy identification of the parasite. Treatment depends on the form, with antimony recommended for cutaneous and mucocutaneous disease and liposomal amphotericin B for visceral disease.

1. Introduction
• Leishmaniasis is a parasitic disease transmitted by the
bite of sand flies.
• Three main forms of leishmaniasis
• Cutaneous: involving the skin at the site of a sandfly bite
• Visceral: involving liver, spleen, and bone marrow
• Mucocutaneous: involving mucous membranes of the mouth and nose
after spread from a nearby cutaneous lesion (very rare)
• Different species of Leishmania cause different forms of disease

2. Introduction
• In the Middle East L. major and L. tropica are the most
common species
• L. major causes skin infection
• L. tropica causes skin and visceral infection and rarely causes
mucocutaneous infection
• About 1.5 million new cases of cutaneous leishmaniasis in
the world each year
• 500,000 new cases of visceral leishmaniasis estimated to
occur each year also
• 20 cases of cutaneous leishmaniasis from L. major/ L
tropica and twelve cases of visceral infection caused by L.
tropica were reported in soldiers from Desert Storm

3. Scientific classification
Domain: Eukaryota
(unranked): Excavata
Phylum: Euglenozoa
Class: Kinetoplastida
Order: Trypanosomatida
Genus: Leishmania

4. •The leishmaniasis is endemic in 88 countries on five
continents—Africa, Asia, Europe, North America and
South America.
•350 million people at risk.
•12 million people are affected by leishmaniasis
•1.5-2 million new cases of leishmaniasis estimated to
occur annually.
• 500 000 new cases of VL which occur annually
GEOGRAPHICAL DISTRIBUTION

5. Endemic Areas for Leishmaniasis

6. Leishmaniasis in the Middle East
• 90% of cutaneous leishmaniasis occurs in Afghanistan,
Iran, Saudi Arabia, Syria, Brazil and Peru
• 8,779 cases were reported in Iraq in 1992
• Sore is commonly called the Baghdad boil
• At least 20 cases of cutaneous leishmaniasis were reported in
Americans from Desert Storm
• 90% of all visceral leishmaniasis occurs in Bangladesh,
Brazil, India, and the Sudan
• 2893 cases were reported in Iraq in 2001
• 12 visceral leish cases were reported in Americans in Desert Storm
• 90% of mucocutaneous leishmaniasis occurs in Bolivia,
Brazil and Peru
• Rarely associated with L tropica which is found in Middle East

7. sand fly Phlebotomus

8. Pathology of Leishmania
1. Varies depending on species
a. May be cutaneous - forming lesion on
skin.
b. May be mucocutaneous - lesion on
mucous membranes with subsequent
tissue erosion.
c. can be visceral - erosion of viscera,
usually fatal.

9. However,
1. Cleared cases can lead to Postkala-azar dermatoid.
a. Horrible disfiguring
b. Can be cured with drugs.

10. Cutaneous Leishmaniasis
• Most common form
• Characterized by one or more sores, papules or nodules
on the skin
• Sores can change in size and appearance over time
• Often described as looking some what like a volcano
with a raised edge and central crater
• Sores are usually painless but can become painful if
secondarily infected
• Swollen lymph nodes may be present near the sores
(under the arm if the sores are on the arm or hand…)

11. Cutaneous Leishmaniasis
• Most sores develop within a few weeks of the sandfly
bite, however they can appear up to months later
• Skin sores of cutaneous leishmaniasis can heal on their
own, but this can take months or even years
• Sores can leave significant scars and be disfiguring if
they occur on the face
• If infection is from L. tropica it can spread to
contiguous mucous membranes (upper lip to nose)

14. Visceral Leishmaniasis
• Symptoms usually occur months after sandfly bite
- Soldiers from Desert Storm presented up to five months
after leaving the Persian Gulf
• Because symptoms are non-specific and often start
after redeployment there is usually a delay in
diagnosis
• Visceral leishmaniasis should be considered in any
chronic FEVER patient returning from an endemic
area.

15. Visceral Leishmaniasis
• Most severe form of the disease, may be fatal if left untreated
• Usually associated with fever, weight loss, and an enlarged
spleen and liver
• Anemia (low RBC), leukopenia (low WBC), and
thrombocytopenia (low platelets) are common
• Lymphadenopathy may be present
• Visceral disease from the Middle East is usually milder with
less specific findings than visceral leishmaniasis from other
areas of the world

16. L. donovani Pathology
1. Slow onset of fever,
later involvement of
viscera,
2. Later abdominal
edema, splenic
enlargment.
a. Often fatal, but
also can spontaneously
clear.

18. Mucocutaneous Leishmaniasis
• Occurs with Leishmania species from Central and South
America
• Very rarely associated with L. tropica which is found in the
Middle East
- This type occurs if a cutaneous lesion on the face
spreads to involve the nose or mouth
- This rare mucosal involvement may occur if a skin
lesion near the mouth or nose is not treated
• May occur months to years after original skin lesion
• Hard to confirm diagnosis as few parasites are in the lesion
• Lesions can be very disfiguring

19. Mucocutaneous Leishmaniasis

20. LIFE CYCLE

21. Amastigotes of Leishmania

22. 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 different tissues.
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 into
promastigotes.
7. They multiply and migrate to the proboscis.
Life cycle

23. Diagnosis: Cutaneous Leishmaniasis
• Biopsy is required for diagnosis
• Biopsy can be done locally if trained medical personnel are available AND
Leishmania diagnostic capability present
• If trained personnel and diagnostic capability are not available, patient
should be referred to Walter Reed Army Medical Center
• Biopsy specimens should be sent to Walter Reed (WRAIR) for diagnosis -
Leishmania Diagnostics Laboratory
- Special laboratories will do microscopy, culture and PCR
- Mail out kits/instructions available
• Preliminary results should be ready in less than two weeks

24. Diagnosis:Visceral Leishmaniasis
• Must be considered if diagnosis is to be made
• Presentation is usually very non-specific and should be considered in
febrile patients in / returned from SWA
• Antibodies to Leishmania may be present in patient’s serum but this
will not confirm or exclude the diagnosis
• Diagnosis requires finding Leishmania on biopsy of bone marrow,
liver, enlarged lymph node, or spleen
• Patients should be referred to a Medical Center, for referral on to
Walter Reed Army Medical Center for definitive diagnosis and
management if other etiologies excluded

25. Diagnosis
Mucocutaneous Leishmaniasis
• Early diagnosis and treatment is critical to avoid
disfigurement
• Patients should be referred to Walter Reed Army Medical
Center
• Biopsies should be done but require special training to
avoid further disfigurement
• Biopsies will be evaluated by the same methods and
special laboratories as for cutaneous lesion
• Because few parasites are present, PCR may be particularly useful

26. Treatment
Cutaneous and Mucocutaneous
• Antimony (Pentostam®, Sodium stibogluconate) is the drug
of choice
• Given under an experimental protocol at Walter Reed Army Medical
Center (WRAMC)
• 20 days of intravenous therapy
• Available at WRAMC for all branches of the military
• Requires patient to come to WRAMC
• Fluconazole may decrease healing time in L. major infection
• Biopsy and culture to determine species is required
• Six weeks of therapy is needed

27. Treatment
Visceral Leishmaniasis
• Liposomal amphotericin-B (AmBisome®) is the drug of choice
• 3 mg/kg per day on days 1-5, day 14 and day 21
• Pentostam® is an alternative therapy
• 28 days of therapy is required
• Although AmBisome® is widely available, the difficulty of
accurate diagnosis and the potential severity of visceral
infection suggest possible patients be referred to the Leishmania
Treatment Centers for maximal diagnostic efficiency