LEISHMANIASIS

POSTGRADUATE CLASS
Prof. Walter Jaoko
Dept. of Medical Microbiology
 Objectives

At the end of this lecture you should be able to:

• Describe the epidemiology of leishmaniasis
• Outline the parasite species of causing leishmaniasis
• Describe the life cycle of leishmaniasis
• Describe the clinical presentation of leishmaniasis
• Describe the laboratory diagnosis of leishmaniasis
• Outline the treatment of leishmaniasis
• Discuss prevention and control of leishmaniasis
 INTRODUCTION
• Group of diseases caused by parasites of the
genus Leishmania
• Leishmania are haemoflagellated protozoa
• Disease has wide spectrum depending on the
organs involved
ü Cutaneous
ü Mucocutaneous
ü Visceral
VISCERAL LEISHMANIASIS
 1.0 Introduction

• Leishmania d. donovani - India subcontinent

• L. d. (East Africa), L. d. (Sudan) - East Africa
• L. d. infantum - Mediterranean region
• L. d. chagasi - South and Central America
• Disease in India subcontinent cc East African
disease
• Disease in Mediterranean region cc S & C. America
• Visceral Leishmaniasis - Baringo, Machakos, Kitui,
Meru, Tharaka, Samburu, West Pokot, Nakuru
 3.0 Life cycle
• Adults mate, fertilized female produces microfilariae
• Mf in blood taken up by Chrysops flies
• Mf have diurnal periodicity (8.00 am – 8.00 pm)
• Mf penetrate stomach wall, migrate to flight muscles
then to proboscis
• In flies development to infective stage takes ~10 days
• Mf deposited in bite, develop to adults in s/c nodules
• Takers 5~6 months worms to mature & produce mf
• Adult worms live up to 17 years
 2.0 Morphology
• Amastigotes
– Oval
– Nucleus
– Kinetoplast

• Promastigotes
– Oval
– Nucleus
– Kinetoplast
– Flagellum
Phlebotomus fly, vector for
leishmaniasis
 3.0 Life cycle
• Bite by phlebotomine fly, picks amastigotes
• Develop to promastigotes
• Regurgitate flagellated promastigotes into skin:
sandfly saliva facilitates & enhances infectivity
• Phagocytosed & transformed into amastigotes in MQ
• Multiply by binary fusion
• Rupture, release & infection of other MQ
• Taken up by sandfly, transform, infective 7D
 4.0 Clinical presentation
• Leishmanioma at sie of bite
• Fever - irregular
• Pallor, bleeding easily from nose (epistaxis), gums
etc
• Recurrent infections - respiratory including TB, GIT
• Splenomegaly, hepatomegaly, Lymphadenopathy
• Cough - usually dry
• Diarrhoea - may include dysentery
• Hyper-pigmentation of the skin
• Peripheral oedema, ascites
Hepato-splenomegaly, ascites in visceral leishmaniasis
 5.0 Diagnosis

• History – clinical & geographical

• Aspirate (Splenic, BM, Liver, LN) – smear, stain with
Giemsa, microscopy (Amastigotes)
• Culture – NNN (Nicole, Novey, McNeal), RPMI or
Schneider (promastigotes)
• Leishmanin skin test (Montenegro test)
• Formal gel test
• Serology – ELISA, IHA, IFAT
• Haemogram - Pancytopenia
 6.0 Treatment
• Sodium stibogulconate (SS)
• Amphotericin B
• Aminosidine (Paromomycin)

East Africa: SS 20 mg/kg (IM/IV) + Paromomycin 15 mg/kg

(IM) given for 17 days; Liposomal amphotericin B - 2nd line:
rescue treatment & for specific target groups e.g. pregnant
women, severe disease or HIV co-infection

Oral drug
• Miltefosine (registered in India); trials ongoing in E. Africa
 7.0 Prevention & Control

• Environmental - houses far from forest edge, swamps

• Vector control - larvicides
• Personal protection - insect repellents
CUTANEOUS LEISHMANIASIS

Walter Jaoko
 Introduction-1

• Cutaneous Leishmaniasis in 80 countries

• 200 M at risk, 300,000 new infections annually
• Americas, Europe, Middle East, Asia, Africa
• Occurs in 80 countries
• Epidemics – non-immune population into
endemic areas (tourists, soldiers, new settlers,
construction or agricultural workers)
• SE factors, pop growth, migration influence
epideminology of CL.
 Introduction-2

• Leishmania, haemoflagellates, obligatory IC

parasites
• Old world CL- L. major (rural, reservoir-rodents),
L. tropica (urban, reservoir-dogs), L. ethiopica
(reservoir-hyrax) - (Africa, Middle East, Europe, Asia)
• New world CL - L. mexicana complex (L. m.
mexicana, L. m. amazonensis, L. venezuelensis),
L. brazilliensis complex (L. b. brazilliensis, L. b.
peruviana, L. b. guyanensis, L. b. panamensis)
– (Central & South America)
 Introduction-3

• In Kenya
• L. tropica – Laikipia, Baringo, Nyandarua,
Nakuru
• L. major – Laikipia, Baringo, Nyandarua,
Nakuru, Kajiado
• L. ethiopica – Reservior – Rock hyrax,
Kenya (Mt. Elgon region), ethiopian
highlands
 Morphology

• Amastigotes
– Oval
– Nucleus
– Kinetoplast
• Promastigotes
– Oval
– Nucleus
– Kinetoplast
– flagellum
Vector
 Life cycle

• Bite by phlebotomine fly, picks amastigotes

• Develop to promastigotes
• Regurgitate flagellated promastigotes into skin:
sandfly saliva facilitates & enhances infectivity
• Taken by skin RE cells, transform to amastigote
• Multiply by binary fusion
• Rupture, release & infectn of other skin RE cells
• Taken up by sandfly, transform, infective 7D
(Restriction to the skin ? temperature sensitivity)
 Clinical presentation-1

• Incubation period 6 M (few months to years)

• Leishmanioma, papules - crusts - skin ulcers
with raised ages - L. tropica (single, dry), L.
major (multiple, wet); 20 bacteria infection;
self-limiting (slow healing) - L. major (1-2 y),
L. tropica (½ to 1 y). Life-long immunity. L.
major (both major & tropica), L. tropica (L.
tropica only)
• Nodules - L. ethiopica, Not self-limiting, no
immunity, diffuse cutaneous leishmaniasis
Clinical presentation-2
Clinical presentation-3
Clinical presentation-4
 Laboratory diagnosis -1

• Aspirate from the lesions – smear, stain with

Giemsa, look for amastigotes
Laboratory diagnosis -2
 Laboratory diagnosis -3

• Histology – stain with Haematoxylin & Eosin,

look for amastigotes
 Treatment
• Local
– Cryosurgery, - Heat therapy
– Surgery + skin graft
– Aminosidine ointment (15%)
• Systemic (severe & non-limiting cases)
– Sodium stibogluconate, Pentamidine
– Amphotericin B
– Ketoconazole, itraconazole (oral drugs)
• Oral
– Ketoconazole, itraconazole, dapsone, allopurinol,
rifampicim
CUTANEOUS LEISHMANIASIS
 Introduction
• Caused by Leishmania brazilliense brazilliense
• Espundia
• Involves mucosal surfaces of the nasal cavity,
palate, rectum etc
• Severe and debilitating disease
Clinical presentation-5