Leishmaniasis
Key Points
Key Points
- The clinical manifestations of infection caused by protozoa of the genus Leishmania are variable and reflect a complex interplay between the human host’s cell-mediated immune responses and the virulence and tropism of the infecting Leishmania species.
- Each leishmaniasis-endemic region has particular combinations of parasite species/strains, sand fly species, mammalian reservoir hosts (in zoonotic transmission cycles), and human hosts with different genetic backgrounds.
- Although Leishmania infection can be subclinical, the three main clinical syndromes are cutaneous leishmaniasis (CL), mucosal leishmaniasis (mL), and visceral leishmaniasis (VL). Less common presentations include diffuse cutaneous leishmaniasis, disseminated cutaneous leishmaniasis, leishmaniasis recidivans, bubonic leishmaniasis, uveitis, and post kala-azar dermal leishmaniasis (PKDL).
- VL, and less commonly CL or mL, may be opportunistic infections in persons who are immunocompromised because of HIV/AIDS or other reasons.
- The only FDA-approved medications for leishmaniasis are intravenous liposomal amphotericin B (L-AmB) for VL, and oral miltefosine for CL, mL, and VL caused by particular species.
- For prevention of leishmaniasis, no prophylactic medications or vaccines are currently available.
- Travelers should use personal protective measures (PPM) that minimize vector exposure whenever they are in leishmaniasis-endemic areas. These measures include protective clothing, insect repellents such as DEET applied to exposed skin, permethrin applied to clothing, window coverings, and insecticide-impregnated bed nets.
- Persons with a history of leishmaniasis (particularly, but not only, VL) should refrain from donating blood.
Figure 1. Sand Flies that Transmit the Leishmania Parasites
Image courtesy of CDC. Available at: http://www.cdc.gov/parasites/leishmaniasis/
Figure 2. Maps of the Geographic Distribution of Cutaneous Leishmaniasis (CL)
Adapted and modified from Chapter 277, Leishmania species. Principles and Practice of Infectious Diseases. Elsevier 2015; 8th edition: 3091-3107.
In Guatemala, the reported cases of 1CL have been acquired in the northern departments (particularly, El Petén and Alta Verapaz but also Izabal, El Quiché, Baja Verapaz, and Jalapa).
The etiologic agents of 2CL in Israel primarily include L. major and L. tropica but also L. infantum-chagasi.
3 The species L. (Leishmania) martiniquensis, which was formally named in 2014, has been identified as the etiologic agent of cutaneous and visceral leishmaniasis in the French West Indies (Martinique Island) and Thailand, where it previously was referred to as “L. siamenensis” (not considered a taxonomically valid name).
4 In Sri Lanka, L. donovani has been identified as the etiologic agent of cutaneous and visceral leishmaniasis.
5 Not all Leishmania species that cause CL are included in this map (eg, L. amazonensis in South America).
Figure 3. Maps of the Geographic Distribution of Visceral Leishmaniasis (VL)
Figure 4. Clinical photographs of Cutaneous Leishmaniasis (CL)
B. L. tropica CL, with thick crusted eschar that should be debrided before diagnostic testing or topical treatment. Photograph from Moshe Ephros
C and D: Before and after treatment of a L. major lesion, demonstrating the scarring nature of this infection. Photographs from Naomi Aronson
E. Nodular lesion caused by L. infantum infection, acquired in Sicily. Photograph from Christina Coyle, Albert Einstein University, NY
F. L. tropica leishmaniasis recidivans, with stereotypical recurrence around the edge of a scar on the face. Photograph from Moshe Ephros
G and H. Secondary infection of CL lesions: G shows suppurative staphylococcal superinfection, and H shows impetiginous streptococcal superinfection. Purulence is not typical of CL unless secondarily infected. Photograph from Naomi Aronson
I. L. mexicana ulcerative lesion of the ear (Chiclero’s ulcer), with a superficial necrotic appearance and edema. Photograph from Naomi Aronson
J. L. (V.) panamensis infection of the eyelid. Photograph from Naomi Aronson
K. Sporotrichoid NWCL; note the subcutaneous nodules along the lymphatic drainage and two large ulcerative lesions. Photograph from Peter Weina
L. Phlebitic change and large ragged ulcer caused by L. major infection acquired in northern Afghanistan. Photograph from Naomi Aronson
M. CL lesion over colored tattoo. Photograph from Naomi Aronson
N. Multiple small cicumferential papules that formed soon after initiation of therapy for a plaque-like lesion caused by L. major. Photograph from Naomi Aronson
O. Verrucous CL on the tip of the nose of a patient in Afghanistan. Photograph from Peter Weina.
Diagnosis
...agnosis
.... The Panel recommends using multiple diagnos...
...nel recommends attempting parasite iso...
...olecular amplification assays typically should...
...shmania skin testing is NOT recommended or availab...
...he Panel suggests that identification of...
...assays should be performed, especially if other...
...Leishmaniasis (CL)...
...the most common syndrome worldwide and the...
...Tissue specimens should be collected from...
...Obtain a sample from a cleansed lesion...
...c testing is not recommended as part of the d...
...Leishmaniasis (ML)...
...mania species with an increased risk of...
...nitial and most prominent mucosal manifes...
...1. Mucosal areas that have macroscopic abnorma...
...l persons at risk for ML—on the basis of the...
...evaluations (ie, initial and subsequent...
...s at risk for ML should be educate...
...ns at risk for ML who have persistent mucosal symp...
...linicians might refer some at-risk persons wi...
Visceral Leishmanias...
...tes (the tissue stage of the parasite) disseminat...
...e Panel recommends the collection of tissu...
...marrow aspiration is the preferred first source o...
...erum should be collected for detection of a...
...munocompromised persons, blood should be coll...
...ic testing is recommended for persons with suspect...
.... The Panel suggests that tests for antileishmania...
Treatment
...atment...
...us Leishmaniasis (CL)...
...recommendations for CL are not straightf...
...reful diagnostic evaluation in which...
...The Panel recommends that immunocompetent person...
25. For persons with CL when the Leishmania s...
...Panel suggests that systemic treatm...
...Panel recommends that any decision to observ...
...cases of CL, wound care, individualiz...
...adequate Treat...
...tial consequences of inadequate treatment inc...
...ns with CL should be actively monitored by...
...such as chronic nasal stuffiness, epistaxis,...
...temic Treatmen...
...c treatment is recommended for persons with co...
...stemic therapy (see Recs. 35–37) may be...
...cutaneous syndromes, such as leishmaniasis reci...
...ral options for systemic therapy currentl...
...ze effectiveness and to minimize to...
...ors that should be considered when selecting CL t...
...cal Settings
...erapy is preferred for treatment of O...
...9. Eschar(s) overlying ulcers should be de...
...sponse Assessment...
...Response to treatment is assessed by clinical...
...ns with CL should have their skin lesi...
...ment Failure...
...therapy is recommended (but not neces...
...ltation with a leishmaniasis expert abou...
...able 1. Clinical Characteristics o...
...ucosal Leishmaniasis (CL)
...with clinically manifest, metastatic, Americ...
...Before treatment is initiated, a c...
46. The Panel recommends inpatient...
...he choice of antileishmanial agent, dose, and d...
...eral Leishmaniasis (VL)...
...ly life threatening and requires prompt...
...ecommends that persons with clinical ab...
...The Panel suggests that clinicians closely...
...or an immunocompetent person with VL, treatment...
51. For an immunocompetent person with VL ca...
.... Pentavalent antimonial therapy (20...
...does NOT recommend switching to amphoterici...
...esponse Assessment
...cal parameters correlate well with parasitologic...
.... Parasitologic confirmation of response...
...atment Failur...
...6. Immunocompetent persons with VL who do n...
...7. Immunocompetent persons with VL...
...etent persons with VL who respond to initial...
...therapies may be considered but have not...
...munocompromised Ho...
...idelines, immunocompetent VL refers to person...
...amphotericin B (L-AmB) is recommended f...
.... Combination therapy (eg, L-AmB plus miltef...
...persons, antiretroviral therapy (ART) sho...
...shmania infection that becomes clinically manif...
.... The Panel recommends administering secondary p...
...ons with VL-HIV/AIDS coinfection should be mo...
...CIATED CL or ML in North America...
...In HIV/AIDS-associated CL/ML, systemic antileishm...
...he systemic regimens used for CL/ML i...
...iral therapy (ART) should be initia...
...mpromised Hosts With Solid Organ Transplant...
...9. Liposomal amphotericin B (L-AmB...
...of immunosuppressive drugs should be decreased i...
...econdary prophylaxis is NOT recomme...
...serologic screening of organ donors from lei...
...Panel suggests that clinicians NOT ro...
...essed persons with VL who are not coinfected with...
...VL therapeutic failure typically can be managed b...
...Panel suggests that CL/mL associated...
...pecial Populat...
.... In general, clinically manifest cases of VL...
...regarding whether and how to treat cases of CL...
...niasis Reference Diagnostic Laborator...
...able 3a. Approach to Syndromic Treatment...
...le 3b. Approach to Syndromic Treatment of...
...le 3c. Approach to Syndromic Treatment of...
...for Tables 3a, 3b & 3c For simplicity, the termi...
...4. Drugs Used in North America for S...