Leishmaniasis

Question 1

Leishmaniasis is Neglected Disease

Answer 1

Leishmaniasis is a globally important but neglected disease, affecting approximately two million people every year. For most people, infection results in a slow-to-heal skin ulcer. In others, however, the parasite targets the liver, spleen and bone marrow, leading to over 70,000 deaths annually.

Question 2

What is the Parasite causing the disease and its taxonomy? (Mostly phylum and species)

Answer 2

Phylum Sarcomastigophora

Order Kinetoplastida

Family Trypanosomatidae

Genus Leishmania

Question 3

Types of Leishmania Parasites and Diseases

Answer 3

Skin:Cutaneous leishmaniasis
* Leishmania tropica
* Leishmania major
* Leishmania aethiopica
* Leishmania mexicana

Skin and mucous membrane: Mucocutaneous leishmaniasis
* Leishmania braziliensis

Organs:
Visceral leishmaniasis e.g
* Leishmania donovani
* Leishmania infantum
* Leishmania chagasi

Question 4

Morphology

Answer 4

Promastigote (flagellated)
Amastigote (non-flagellated)

Question 5

Morphology of Amastigotes

Answer 5

Amastigotes

• measure 2-3 micrometers, with a large nucleus and Kinetoplast.
• Amastigotes mainly live within cells of the RE system, but have been found in nearly every tissue and fluid of the body.
• flagella is absent

Question 6

Which species of Leishmania are Endemic in Saudi Arabia?

Answer 6

Leishmania donovani
Leishmania infantum
Leishmania tropica
Leishmania major

Question 7

What is Kala-Azar

Answer 7

Kala-azar means dark pigmentation which is characteristic of cases of visceral leishmaniasis. It is caused by Leishmania donovani bodies and may be present either in endemic, epidemic or sporadic forms. It is widely prevalent in India in epidemic form in states of Bihar, Assam and Bengal. Kala azar found in East and North Africa is a disease of young children and young adults, being more common in males as compared to females.

Question 8

Clinical types of cutaneous leishmaniasis

Answer 8

Leishmania major: Zoonotic cutaneous leishmaniasis: wet lesions with severe reaction

Leishmania tropica: Anthropologic cutaneous leishmaniasis: Dry lesions with minimal ulceration
Oriental sore (most common) classical self-limited ulcer

Question 9

How is it transmitted

Question 10

KALA AZAR

Answer 10

Leishmaniasis is a disease caused by protozoan parasites of to the genus Leishmania and is transmitted by the bite of sand fly.
This disease is also known as kala azar, black fever, sandfly disease, Dum-Dum fever.
Human infection is caused by about 21 of 30 species that infect mammals. These include the L. donovani complex with three species (L. donovani,
L. infantum, and L. chagasi

Question 11

Uncommon types

Answer 11

Diffuse cutaneous leishmaniasis (DCL):
Caused by L. aethiopica, diffuse nodular non- ulcerating lesions. Low immunity to Leishmania antigens, numerous parasites.
Leishmaniasis recidiva (lupoid leishmaniasis):
Severe immunological reaction to Leishmania antigen leading to persistent dry skin lesions, few parasites.

Question 12

Post Kala-azar Dermal Leishmaniasis

Answer 12

Post Kala-azar Dermal Leishmaniasis (PKDL) is a condition when Leishmania donovani invades skin cells, resides and develops there and manifests as dermal leisions. Some of the kala-azar cases manifests PKDL after a few years of treatment. Recently it is believed that PKDL may appear without passing through visceral stage.

Question 13

Pathogenesis of kala azar

Answer 13

Infections range from asymptomatic to progressive, fully developed kala-azar.

Incubation period is usually 2 – 4 months.
Symptoms – Begins with low-grade fever and malaise, followed by progressive wasting, anemia, and protrusion of the abdomen from enlarged liver and spleen.

Fatal after 2 – 3 years if not treated.
In acute cases with chills, fevers up to 104 degrees Fahrenheit, and vomiting; death may occur within 6 – 12 months.

Immediate cause of death is usually an invasion of a secondary pathogen that the body is unable to combat.

Question 14

Life cycle

Answer 14

1. The sandflies inject the infective stage (i.e., promastigotes) from their proboscis during blood meals
2. Promastigotes that reach the puncture wound are phagocytized by macrophages
3. Promastigotes transform in these cells into the tissue stage of the parasite-amastigotes, destroy the macrophage and are then released
4. multiply by simple division and proceed to infect other mononuclear phagocytic cells and amastigote infects other cells
5. Sandflies become infected by ingesting infected cells during blood meals
6. they are ingested into the midgut
7. amastigotes transform into promastigotes, develop in the anterior gut and pharynx
8. they migrate to the proboscis

Dogs and rodents are common reservoirs.

Question 15

L. tropica
Host and Clinical features?

Answer 15

Host: Dogs
CF: Oriental sore(Baghdad
boil)

Question 16

L. major
Host and Clinical features?

Answer 16

Host: Gerbils, desert rodents
CF: Rapid necrosis, wet sores

Question 17

L. aethiopica
Host and Clinical features?

Answer 17

Host: Hydraxes
CF: Solitary facial lesions with satellites

Question 18

Diagnosis of Cutaneous leishmaniasis

Answer 18

Smear: Giemsa stain – microscopy for LD bodies (Amastigote)

Biopsy: microscopy for LD bodies or culture in NNN medium for promastigotes

Question 19

What type of specimen is used for diagnostic testing?

Answer 19

L. donovani bodies may be demonstrated in buffy coat preparations of blood and bone marrow aspirate.

Aspirates taken from enlarged lymph nodes show parasites in 60 percent of cases.

Question 20

Diagnosis of Visceral leishmaniasis

What specimen is used for diagnotic testing?

Answer 20

Microscopy and culture in NNN medium

Specimen:
Bone marrow aspirate Splenic aspirate
Lymph node
Tissue biopsy

Question 21

Diagnostic Methods in Leishmaniasis include:

Answer 21

Antibody detection. Specific sero diagnostic tests are also employed. Conventional methods include gel diffusion, complement fixation test, indirect haem agglutination test, indirect immuno-fluorescent antibody test (IFAT) and counter immuno electro phoresis. Most of these tests have limited sensitivities and specifies.

Question 22

Culturing of the Parasite

Answer 22

Organisms can be cultured in Nicolle- NovyMacneal (NNN media) media from clinical specimens obtained from splenic or bone marrow aspirates.

Question 23

Immunological Diagnosis

Answer 23

Specific serologic tests: Direct Agglutination Test (DAT), ELISA, IFAT
Skin test (leishmanin test) for survey of populations and follow-up after treatment.

Non specific detection of hypergammaglobulinaem by formaldehyde (formal-gel) test or by electrophoresis.

Question 24

Direct agglutination test

Answer 24

Direct agglutination test (DAT) based on agglutination of the trypsenized whole promastigotes is useful in endemic regions. Its sensitivity ranges from 91-100% and specificity from 72 to 100%.

Question 25

ELISA

Answer 25

ELISA is an important sero diagnostic tool for leishmaniasis. It is a highly sensitive test and its specificity depends upon the antigen used.

Question 26

Chromatographic strip test

Answer 26

A ready to use immuno chromatographic strip test based on rk 39 antigen has been developed as a rapid test for diagnosis of kala azar. An important limitation of this test is the presence of antibodies in healthy controls hailing from endemic regions.

Question 27

Treatment

Answer 27

Pentavalent antimony (Pentostam)
Amphotericin B
Treatment of complications:
Anemia
Bleeding
Infections etc.

Question 28

Management of Kala-azar Patients

Answer 28

It includes both supportive and curative. All patients of Kala azar should preferably be hospitalized. Any infection complicating the disease be treated by use of proper antibiotics. Nutrition must be maintained. Cases with severe anemia may require blood transfusions. Pentavalent antimony compounds are the drug of choice. Sodium antimony gluconate (Pentostam) is the most commonly used drug.

Question 28

Kala-azar prevention

Answer 28

Multipronged approach is needed.

Sand-flies are extremely sensitive to insecticides & vector control through insecticide spray is very important.

Mosquito nets or curtains treated with insecticides will keep out the tiny sand-flies.

In endemic areas with zoonotic transmission, infected or stray dogs should be destroyed.

In areas with anthroponotic transmission, early diagnosis & treatment of human infections, to reduce the reservoir & control epidemics of VL, is extremely important.

Serology is useful for screening of suspected cases in the field.

No vaccine is currently available .