Leishmaniasis Flashcards
What is leishmaniasis caused by?
Protozoa that survive and replicate within macrophages and other mononuclear cells.
How many species of Leishmania cause human disease?
Over 20 species.
What are the main forms of leishmaniasis?
- Visceral leishmaniasis
- Cutaneous leishmaniasis
- Mucosal leishmaniasis
In how many countries does leishmaniasis occur?
99 countries or territories.
What was the estimated annual incidence of new leishmaniasis cases?
1 million new cases annually.
Which Leishmania species are primarily responsible for visceral leishmaniasis?
- L. donovani
- L. infantum (syn. L. chagasi)
- L. (Mundinia) martiniquensis
What are the prevalent species causing cutaneous leishmaniasis in the Americas?
- L. braziliensis
- L. guyanensis
- L. panamensis
- L. peruviana
- L. mexicana
- L. amazonensis
True or False: Fewer than 100 autochthonous cases of leishmaniasis have been recognized in the US in the past 100 years.
True.
What is the significance of HIV-leishmaniasis coinfection?
It poses a growing problem in parts of Asia, Africa, and Latin America.
How is leishmaniasis usually spread in endemic areas?
By infected sand flies of the genera Phlebotomus and Lutzomyia.
What is a key factor in the transmission of Leishmania among drug users?
Needle sharing and contaminated syringes.
What are the main clinical manifestations of leishmaniasis?
- Cutaneous leishmaniasis
- Visceral leishmaniasis
- Mucosal leishmaniasis
- Disseminated cutaneous leishmaniasis
- Diffuse cutaneous leishmaniasis
- Post-kala-azar dermal leishmaniasis
What percentage of people with HIV-leishmaniasis coinfection in Europe have visceral disease?
95%.
What is the typical hemoglobin level in people with HIV and visceral leishmaniasis?
<10 g hemoglobin/dL.
What is a common atypical manifestation of leishmaniasis in people with advanced immunosuppression?
Mucosal involvement.
How does cutaneous leishmaniasis present in people with HIV with high CD4 counts?
Similar to those without HIV, but with a higher rate of relapse.
Which species are commonly associated with mucosal leishmaniasis in people with HIV?
- L. braziliensis
- L. guyanensis
- L. panamensis
What is the standard method for diagnosing cutaneous leishmaniasis?
Demonstration of Leishmania parasites by histopathology, cultures, smears, and molecular methods.
What is the preferred method for diagnosing visceral leishmaniasis in people with HIV?
Demonstration of leishmanial parasites in bone marrow aspirates.
What is the best way to prevent leishmanial infection for travelers?
Protecting against sand fly bites.
True or False: A vaccine against leishmaniasis is currently available.
False.
What is the preferred therapy for visceral leishmaniasis caused by L. infantum/chagasi?
Liposomal amphotericin B, achieving a total dose of 20–60 mg/kg.
What is the indication for chronic maintenance therapy in visceral leishmaniasis?
For patients with visceral leishmaniasis and CD4 count <200 cells/mm3.
Fill in the blank: The presence of Leishmania amastigotes in skin can occur in the absence of _______.
lesions.
What is the alternative therapy for visceral leishmaniasis if liposomal amphotericin B is not available?
- Amphotericin B deoxycholate
- Pentavalent antimony (meglumine antimoniate)
What is the minimum CD4 count for considering treatment for visceral leishmaniasis?
> 350 cells/mm3
What should be initiated as soon as possible for patients with cutaneous leishmaniasis?
ART (antiretroviral therapy)
Initiation or optimization of ART may prevent reactivation of cutaneous leishmaniasis.
What is the preferred therapy for cutaneous leishmaniasis?
- Liposomal amphotericin B 4 mg/kg IV daily for 10 days or interrupted schedule
- Miltefosine 2.5 mg/kg/day PO for 28 days
- Pentavalent antimony 20 mg/kg IV or IM daily for 28 days
What are alternative therapies for cutaneous leishmaniasis?
- Cryotherapy
- Topical paromomycin
- Intralesional pentavalent antimony
- Pentamidine
- Fluconazole for L. major and L. mexicana
- Intravenous pentamidine
- Local heat therapy
When is chronic maintenance therapy for cutaneous leishmaniasis indicated?
For immunocompromised patients with multiple relapses
What is the first choice for therapy of visceral leishmaniasis in pregnancy?
Liposomal amphotericin B
What can be given as an alternative therapy for visceral leishmaniasis in pregnancy?
Amphotericin B deoxycholate
In many uncomplicated cases of cutaneous leishmaniasis, when can treatment be delayed?
Until postpartum
What should patients treated with amphotericin B be monitored for?
- Dose-dependent nephrotoxicity
- Electrolyte disturbances
- Infusion-related adverse reactions
What are the recommended regimens for liposomal amphotericin B in visceral leishmaniasis?
- 3 to 5 mg/kg body weight on consecutive days
- Interruption schedule (e.g., 4 mg/kg on Days 1–5, 10, 17, 24, 31, and 38)
What is the dosage for pentavalent antimony in visceral leishmaniasis?
20 mg/kg/day IV or IM for 28 consecutive days
What is the recommended oral miltefosine dosage for visceral leishmaniasis caused by L. donovani?
Approximately 2.5 to 3 mg/kg daily (maximum of 150 mg daily) for 28 days
What should be done prior to starting therapy with pentavalent antimony?
Obtain a pregnancy test (beta-human chorionic gonadotropin [β-hCG])
What is a common adverse event associated with miltefosine?
Gastrointestinal symptoms
More commonly nausea or vomiting than diarrhea
What should be monitored weekly in patients receiving miltefosine?
- Renal function
- Hepatic function
- Platelet counts
What is the recommended follow-up for people with HIV successfully treated for visceral leishmaniasis?
Clinical monitoring for symptoms or signs of recurrence
What is the relapse risk for people with HIV and visceral leishmaniasis who are not on ART?
60% at 6 months and 90% at 12 months
What should be done for patients who fail to respond to initial therapy for leishmaniasis?
A repeat course of the initial regimen or one of the recommended alternatives
What are the risks associated with low CD4 count in patients with visceral leishmaniasis?
Higher relapse rates
What should be considered when treating cutaneous leishmaniasis in patients with HIV?
Systemic therapy depending on the type of cutaneous leishmaniasis and clinical response
What is the significance of a positive peripheral blood PCR for Leishmania in patients with HIV?
Correlated with a high risk of relapse
What are the reported associations with relapse in visceral leishmaniasis?
Prior episode of visceral leishmaniasis, CD4 count <100 cells/mm3 at time of primary visceral leishmaniasis, no increase in CD4 count at follow-up.
Relapse is significantly influenced by the patient’s immune status and history of the disease.
What is the risk of relapse at 6 and 12 months for HIV-visceral leishmaniasis coinfection without secondary prophylaxis?
60% at 6 months and 90% at 12 months.
This highlights the importance of secondary prophylaxis in managing coinfections.
What is the recommended frequency for administering secondary prophylaxis with an effective antileishmanial drug?
At least every 4 weeks.
This is particularly crucial for patients with visceral leishmaniasis and CD4 counts <200 cells/mm3.
What were the relapse rates reported in the randomized trial comparing amphotericin B lipid complex with no prophylaxis?
50% with prophylaxis versus 78% without prophylaxis after 1 year.
This indicates the efficacy of prophylaxis in preventing relapse.
What is the preferred regimen for secondary prophylaxis?
Liposomal amphotericin B (4 mg/kg every 2–4 weeks).
This regimen is recommended due to its effectiveness.
List alternatives to liposomal amphotericin B for secondary prophylaxis.
- Amphotericin B lipid complex (3 mg/kg every 21 days)
- Pentavalent antimony (20 mg/kg IV or IM every 4 weeks)
- Pentamidine isethionate (4 mg/kg IV every 2 to 4 weeks)
Each alternative has its own indications and recommendations.
When can secondary prophylaxis potentially be discontinued?
When CD4 count is >350 cells/mm3 and HIV viral load is undetectable for 6 months.
Continuous evaluation of patient status is essential for making this decision.
What concerns exist regarding the use of pentavalent antimony compounds during pregnancy?
They are contraindicated for use in pregnant people due to concerns about toxicity.
Although some studies found no teratogenic effects in animals, human data are lacking.
What is the first choice for therapy of visceral leishmaniasis in pregnancy?
Liposomal amphotericin B.
This choice is based on safety and efficacy data available for pregnant individuals.
What are the risks associated with untreated cutaneous leishmaniasis during pregnancy?
Increased risk of preterm delivery and stillbirth.
Maternal immune modulation during pregnancy may exacerbate these risks.
True or False: Miltefosine is recommended during pregnancy for treating visceral leishmaniasis.
False.
Miltefosine is teratogenic and not recommended in pregnancy.
What was the reported maternal death rate in pregnant individuals treated with liposomal amphotericin?
2.3% maternal deaths reported.
This indicates the overall safety of liposomal amphotericin in pregnant patients.
What is the recommended approach for treating mucosal leishmaniasis in pregnant individuals with HIV?
Systemic therapy is recommended, with liposomal amphotericin B as the treatment of choice.
This reflects the need for effective treatment while considering pregnancy safety.
What is the relationship between a positive peripheral blood PCR for Leishmania and relapse?
It correlates with a high risk of relapse.
Monitoring PCR results can be an important aspect of managing patients.
Fill in the blank: Secondary prophylaxis for visceral leishmaniasis is particularly recommended for patients with CD4 counts ______.
<200 cells/mm3.
This is due to their increased risk of relapse.
What is the relapse-free survival rate for patients with CD4 ≥200 cells/µL after 390 days of follow-up?
53% relapse-free survival.
This suggests better outcomes with higher CD4 counts.
What is the significance of the 36.9% relapse rate in Ethiopian patients with HIV-visceral leishmaniasis coinfection?
Identified over a 2-year follow-up, mainly among those with a low baseline CD4 count.
This emphasizes the importance of monitoring CD4 counts in managing treatment.
What is the recommendation for treating cutaneous leishmaniasis in most individuals with HIV during pregnancy?
Deferring treatment until the postpartum period.
This is due to concerns about potential risks associated with treatment during pregnancy.
