Haemoflagellates

Leishmaniasis (1)

Balsam Elbushra
Background about Haemoflagellates
Blood flagellate are protozoa that moves with flagellum
The flagellum arises from the kinetoplast .
They are transmitted by an insect vector( intermediate
host) that harbors the parasite.
 There are two genera ( Leishmania and Trypanosome
parasites
 Leishmania parasites have two forms
a. Amastigote
b. Promastigote
2. Trypanosome parasites have two forms
a. Epimastigote
b. Trypomastigote
 Leishmania species
• caused by parasites of the genus Leishmania
• transmitted by Phlebotomus species, sandfly.
• The parasites is obligatory intracellular of the
reticuloendothelial cells ( macrophages and monocytes
in blood).
• pass their life cycle in 2hosts—the mammalian host
(Human) and the insect vector (female sandfly)
Phlebtomus .
• cause diseases known as Leishmaniasis
 Three types of disease
Cutaneous Leishmaniasis
L. Tropica complex L. aethiopica
L. major L. mexicana complex

Mucocutaneous leishmaniasis
• L. braziliensis complex

Visceral Leishmaniasis
• L. donovani complex
• infecting internal organs (liver, spleen, and
• bone marrow) of human
 Classification of Leishmania based on
Geographical Distribution

• Leishmania donovani
Old world •
•
Leishmania infantum
Leishmania tropica
leishmaniasis •
•
Leishmania major
Leishmania aethiopica

• Leishmania braziliensis complex

New world • Leishmania mexicana complex
leishmaniasis • Leishmania chagasi
 Morphology
Amastigote or LD (Leishman
Donovan) bodies
- Intracellular Amastigote
oval kinetoplast
- Oval 2-3 μm
- has rounded nucleus. Eccentric nucleus

- Kinetoblast
- Axoneme (the root of the flagellum).
- Has no free flagellum. (aflagellar
stage) Amastigote

- Non motile
Promastigote :
- Spindle shape, elongated
10- 15 μm. Promastigote
elongated kinetoplast
- Has central nucleus.
- Anterior kinetoplast. Central nucleus

- Has Anterior free flagellum.

• Found in culture and insects
( sandy fly).
- It is the infective form of
Leishmania.
- And diagnostic stage when
detect in culture
 Mode of transmission:
• through bite of female of sandflies With promastigote.
Phlebotomus (OW) Lutzomyia (NW)
block mouth & pharynx in skin or blood of patient
Promastigotes Amastigote
Infective stage Diagnostic stage

Alimentary Promastigotes
canal of Multiply by
sand fly
binary fission

Biological
transmission
Pathogenesis & Clinical Picture of Cutaneous Leishmaniasis
Nodule forms at the site of bite due to multiplication of
Leishmania in skin macrophages
& granulomatous reaction around them.
Inflammatory
cells
Amastigotes
Promastigotes
Skin macrophage
forms with sharp-cut edges with raised
An ulcer
indurated margin
In about 1 year
Healing occurs leaving
a disfiguring scar

The patient develops solid immunity

 Cutaneous Leishmaniasis
• Also known as Oriental sore
• the most common form of leishmaniasis
and causes skin lesions, mainly ulcers,
on exposed parts of the body, leaving
life-long scars
 Old World cutaneous leishmaniasis is
caused by
• L. tropica , L. major and L. aethiopica
• Sand fly --- Phlebotomus
 Cutaneous

New world Old worlds

L. mexicana L. tropica

L. amazonensis L. major

L. aethiopica
 New World cutaneous Leishmaniasis is caused by
L. mexicana complex and L. braziliensis complex.
Sand fly--- Lutzomyia
 Leishmania species causing ulcer in the Old World
In the Middle East
1- L. tropica 2- L. major
Oriental sore

Urban Rural
dry chronic wet acute
 I-Cutaneous Leishmaniasis “Oriental Sore”(O.W.C.L)
Single Dry Non-Exudative Lesion -1 Caused by L. tropica
URBAN type
1- Present in towns & cities
2- Long incubation Period (months to years).
3- Lesions develop in exposed parts such as (face –limbs)
4- Lesions are slowly progressive.
5- Ulcer heals “self-limiting infection” scar
tissue form
6- C.M.I. leading to resistance to reinfection

Appear as follows: single-small-Dry-painless nodule-

nonexudative-delayed ulceration-small scar- uncommon 2ry
bacterial infection. non pruritic
Multiple Wet Exudative Lesion -2 Caused by L. major
RURAL type
1- Found in villages at edge of deserts
2- Relatively short incubation period (2-6 weeks).

3- Lesions are more severe than L.tropica – big Ulcers

4- Lesions are rapidly progressive.

5- Dense nodules ulcerate & Coalesce big ulcers

Appear as follows: Multiple-Big-Wet-painless nodule Exudative

2ry bacterial delay healing –Big disfiguring scar- pruritic.
New World cutaneous Leishmaniasis
 L. mexicana complex
• Single
• painless papule which ulcerates
• does not spread
• sand fly bite on the exposed
parts (face and ears). (Chiclero’s ulcer
or Bay sore)
• Lesion in the ear causes
destruction of the cartilage
 symptoms and signs of cutaneous leishmaniasis
 Some people have a silent infection, without
any symptoms or signs
one or more sores on their skin
• sores can change in size and appearance over
time
• The sores may start out as papules or nodules
and end up as ulcers
• The sores typically develop within a few
weeks or months of the sand fly bite.
• The sores usually are painless but can be
painful
 L.Tropica L.Major L.aethiopica

Type of Ulcer Dry Moist Dry

Acute or Chronic Acute

chronic (delayed (Rapid
ulceration and ulceration and
slow healing rspid healing 3-6
1year ) month )
 Diffuse cutaneous leishmaniasis

 It is a rare form of leishmaniasis

Ethiopia, Kenya
• L aethiopica.
South America
• L .mixecana.
• L. amazonensis
• painless , non-healing ,life long , non ulcerates nodules
In patients with deficient cell-mediated immunity (inefficient
cellular I.R)
The Lesions appear as follows:.
1- Multiple nodules with abundant parasite – Rarely ulcerate.
2- Skin becomes thick due to hyperplasia & hypertrophy.
3- The lesion appear as “Lepromatous Leprosy”.
????????
 Mucocutaneous leishmeniasis

• L. braziliensis complex
majority of cases primarily present with Cutaneous Lesion
Deficient C.M.I. Spread of infection either directly or
haematogenously to involve soft tissues of the Oronasal &
Pharyngeal mucosa (NOSE-PHARYNX-LARYNX –UPPER LIP ( Espundia).
• The disease has the same pathology of simple cutaneous
leishmaniasis, but the lesions extend to affect the
mucous membranes of the mouth, nose, pharynx, and
larynx
 Laboratory Diagnosis
Microscopy
• demonstration of amastigote in the
smear collected from the lesion
• sample : material obtained from the
edge of nodule or sore .
• Smear stained by Giemsa or Leishman
stain.
• Stage : Amastigotes are found inside
the macrophages
make incision in active part of scrape cells from incision
lesion
prepare Giemsa-stained smear
 Aspiration and biopsy from the ulcer

Aspiration Scrape or take biopsy

Leishmania
amastigotes
(Giemsa stained)
Culture
NNN ( Novy Macneal and Nicolle) medium

Schneider’s medium
Compsed of :
• Rabbite blood
• Agar
• NACL
• D.W
• Antibiotic ( Penicillin , Gentamycin )
Stage : promastigote
 Culture (22—25 C )---7-21 DAY examine every 2 day
 it is value when smear is – ve
Act as vector
 Advantage
• increase the sensitivity of leishmenia parasite detection
Disadvantage :
•Dely to obtain result
• expensive
•Sterile condition are difficult to achieve in field situation
 Leishmanin skin test :
• Also Known as Montenegro skin test
• delayed hypersensitivity reaction
Method :
• 0.1 ml (well shaken Ag )
• Injected intradermally (inner surface
of forearm )
• Preform the test with accompanying
control solution (N.S) in other
forearm
• 48—72 hour
 Result :
 the diameter 5mm or more --- positive
reaction
the diameter less than 5mm ---Negative
reaction
Comment :
• Positive : cutaneous and mucosal
leishmaniasis
• People from endemic area (No visible
lesions)
• Negative Diffue cutaneous leishmaniasis ,
progressive (active )visceral leishmaniasis .
Disadvantage
• +ve positive (remain for life )
• Cannot differentiate old and
recent infection
• they lack sensitivity and
specificity.
• VL give +VE positive after 6—8
week after cure
Animal inculation
• into hamster or mice

Polymerase chain reaction( PCR)

• for detection and speciation of Leishmania
parasites DNA.