leishmaniasis

2.  Varied collection of protozoal diseases
 Named after Leishman - First identified the organisms
in 1901
 Smears taken from a man who had died of “Dum
Dum” fever
 Annually - Two million cases worldwide
 Has emerged as an AIDS - associated opportunistic
infection

3. 1. Cutaneous
2. Diffuse cutaneous
3. Mucocutaneous
4. Visceral Leishmaniasis (Kala Azar)

4.  Endemic in 88 countries on five continents
 Cutaneous Leishmaniasis cases occur in Iran,
Afghanistan, Syria, Saudi Arabia, Brazil and Peru
 Visceral Leishmaniasis cases occur in
Bangladesh, Brazil, India and Sudan
 World Health Organization estimates that 350
million people are at risk

5.  2.4 million disability - adjusted life years
 Around 7,00,000 deaths per year
 WHO South East Asia Region - 200 million
people in the Region are “at risk”

6.  World’s largest foci of Visceral Leishmaniasis, accounting for
50% of the total burden
 Endemic in 4 states in India:
 Bihar- 32 districts Jharkhand- 4 districts
 West Bengal- 11 districts Uttar Pradesh- 5 districts
 An estimated 165.4 million population is at risk
 About 1,00,000 cases occur annually

7. 

8.  19 protozoan species
 Genus Leishmania
 Amastigote- obligate intracellular parasites and
divide in macrophages- diagnostic phase
 Promastigotes- extracellular present in the
arthropod vectors- infective phase
 Absence of cross immunity

9.  Leishmania donovani complex
 Leishmania donovani, L. infantum and L. chagasi
 Leishmania mexicana complex
 L. mexicana, L. amazonensis and L. venezuelensis
 Leishmania tropica
 Leishmania major
 Leishmania aethiopica
 In India: Leishmania donovani

11.  Female sand flies of the genus Lutzomyia in
the Americas and Phlebotomus in other parts
of the world
 Sandflies breed in cracks and crevices in the
soil and buildings, tree holes and caves
 Sandflies are active in the evening and night -
time hours
 In India, Phlebotomus argentipes is a proven
vector of KalaAzar.

12.  Cutaneous form mainly zoonotic,
- humans are accidentally exposed
 Indian Kala - Azar is anthroponotic with humans
being the only known reservoir of infection
 Peak age of infection is 5 to 9 years
 Males
 Poor socio-economic background
 Common in various farming practices, forestry,
mining and fishing

13.  Mostly confined to the plains
 Overcrowding,
 Poor ventilation
 High relative humidity, warm temperature
 Accumulation of organic matter in the
environment facilitates transmission

14.  Transmitted by the bite of infected female
sandflies
 Rarely: initiated by amastigotes via blood
(shared needles, transfusion, transplacental
spread) or organ transplantation

15.  Incubation period:
 Extremely variable (10 days - 3 to 8 months – 2
yrs)
 Varied presentation:
 Ulcerative skin lesions
 Destructive mucosal inflammation
 Disseminated visceral infection

16.  Typical lesion :
 Develops at the site where promastigotes are
injected by the vector
 A papule - papule enlarges – ulcerates
 Multiple lesions may be present

18.  Infected with Leishmania braziliensis
 Begins with nasal stuffiness and inflammation
 Ulceration of the nasal mucosa and septum
follows.
 The lips, cheeks, soft palate, pharynx and
larynx may eventually be involved, resulting in
substantial disfigurement
 More common among immunosuppressed
with neoplasms or AIDS

19.  Recurrent fever
 Loss of appetite, pallor and weight loss with
progressive emaciation
 Weakness
 Splenomegaly - spleen enlarges rapidly to massive
enlargement, usually soft and non-tender
 Liver - enlargement not to the extent of spleen, soft,
smooth surface, sharp edge

21.  Death often occurs due to a secondary bacterial
infection, such as
 Pneumonia, Septicemia,
 Dysentery, Tuberculosis,
 Measles Other viral infections

22.  Anaemia, Neutropenia, Thrombocytopenia and
pronounced hypergammaglobulinemia.
 The anaemia is usually normocytic, normochromic,
unless there is concomitant iron deficiency
 Leukopenia can be profound with white blood cell
counts below 1000/mL
 The globulin level can reach 9 or 10 g/dl.

23.  Some patients in India and Africa develop skin lesions
following treatment, ranging from hyperpigmented macules
to frank nodules
 Skin lesions typically appear 1 or 2 years after treatment and
may persist for as long as 20 years.
 Persistence of lesions beyond one year is associated with high
anti - leishmanial antibody titers and negative leishmanial skin
test responses
 Anti - leishmanial treatment is indicated in Indian PKDL

24.  Immunocompromised individuals progress to develop the
disease far more often than immunocompetent people
 It quickly accelerates the onset of AIDS and shortens the
life expectancy of HIV - infected people.
 Visceral Leishmaniasis is considered a major contributor
to a fatal outcome HIV in co - infected patients

25.  Parasite Identification:
 Wright-Giemsa stain is used for identifying amastigotes
in tissue sections
 Serology:
 Anti-leishmanial antibody titers are typically present in:
▪ High titer in people with Visceral Leishmaniasis and
▪ Low titer or undetectable in those with Cutaneous
Leishmaniasis.
 Assays such as ELISA, IFAT and agglutination assays,
rk-39 rapid diagnostic test

26.  Skin Test
 Intradermal leishmanin (Montenegro) skin test
Positive Negative
- Asymptomatic
- Self resolving
leishmania
- Following successful
treatment
- Progressive visceral
Leishmaniasis
- Diffuse cutaneous
Leishmaniasis

27.  Aldehyde test
 Napier is a simple test
 1 to 2 ml of serum from a case of kala-azar is taken
and a drop or two of 40 per cent formalin is added.
A positive test is indicated by jellification to milk-
white opacity like the white of a hard-boiled egg
so that in ordinary light newsprint is invisible
through it

28. FIRST LINE OF DRUGS
SHORT TERM LONG TERM
SSG
SENSITIVITY
>90%
SSG
SENSITIVITY
<90%
SSG 20
mg/Kg i.m or
i.v for 20
days
Amphotericin B
1mg/kg i.v daily
or alternate days
SSG
RESISTANCE
>20%
SSG
SENSITIVITY
>80%
MILTEFOSINE
100mg/day
divided doses for
4 weeks
SSG
20mg/kg/ day
i.m/i.v for 30
days
CONTROL OF RESERVOIR

29. SECOND LINE OF DRUGS
SSG FAILURE SSG AND MILTEFOSINE FAILURE
Amphotericin B
1mg/kg i.v daily
or alternate
LIPOSOMAL
AMPHOTERICIN
B

30.  Treatment of PKDL :
 SSG in usual dosage for kala azar
 Could be given for 120 days.
 Repeated 3-4 courses of Amphotericin B can be
given in patients failing SSG treatment.

31.  Sandfly Control: using residual insecticides, DDT used as
the first choice
 BHC may be used as second line of defence
 Santation measures like removal of breeding places
 Personal prophylaxis: The short - term visitor to an
endemic area should use personal protective measures to
avoid sand fly bites
 The application of DEET (diethyltoluamide)
 Use of fine mesh nets
 Application of insect repellants

32. 1. The disease is endemic in following three
countries of the WHO South East Asia Region
except:
(a). Bangladesh (b) India (c) Nepal (d) Sri lanka
2. The disease is reported in _________ no of
districts in India:
(a) 51 (b) 52 (c) 53 (d) 54

33. 3. State which accounts for more than 90 per cent of the
cases in India
(a) Uttar Pradesh (b) Bihar (c) Assam (d) M.P
4. Leishmania donovani complex comprises of all except
(a) Leishmania infantum (b) Leishmania chagasi
(c) Leishmania venezuelensis (d) Leishmania donovani
5. Cutaneous Leishmaniasis is also known as all the following
except
(a) Oriental sore (b) Aleppo evil (c) Delhi boil (d) Espundia
Answers : (1) d; (2) b; (3) b; (4) c; (5) a.