Leishmaniasis

Publication Date: December 7, 2016

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)

A. Typical New World cutaneous leishmaniasis (NWCL) ulcerative lesion caused by Leishmania (Viannia) braziliensis infection acquired in Peru (the patient also had mucosal involvement). Photograph from Chris Ohl, Wake Forest Univ, NC
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

Diagno...

...nel recommends using multiple diagnost...

...l recommends attempting parasite isolat...

...mplification assays typically should...

...ishmania skin testing is NOT recomme...

5. The Panel suggests that identificatio...

...ed assays should be performed, especially i...


...s Leishmaniasis (CL)...

...the most common syndrome worldwide and...

.... Tissue specimens should be collected from a le...

...Obtain a sample from a cleansed lesion, f...

.... Serologic testing is not recommended as p...


...Leishmaniasis (ML)...

...pecies with an increased risk of causing mu...

...tial and most prominent mucosal manifesta...

...reas that have macroscopic abnormalities...

...persons at risk for ML—on the basis of the et...

...ng all evaluations (ie, initial an...

...sons at risk for ML should be educate...

...rsons at risk for ML who have persistent mucosa...

...Clinicians might refer some at-risk per...


...l Leishmaniasis (V...

...amastigotes (the tissue stage of the paras...

...l recommends the collection of tissue as...

...8. Bone marrow aspiration is the pref...

...erum should be collected for detection of...

...In immunocompromised persons, blood should...

.... Serologic testing is recommended for persons...

...2. The Panel suggests that tests for antileishman...


Treatment

...reatme...

...eous Leishmaniasis (...

...recommendations for CL are not straig...

...a careful diagnostic evaluation in which n...

...recommends that immunocompetent persons with skin...

...with CL when the Leishmania species is not kno...

26. The Panel suggests that systemic treatment...

...Panel recommends that any decision to...

...cases of CL, wound care, individualiz...

...adequate Treatment

29. Potential consequences of inadequate treatment...

...CL should be actively monitored by clinic...

...h as chronic nasal stuffiness, epist...

...temic Treatment...

...c treatment is recommended for per...

...ial systemic therapy (see Recs. 35–37)...

...ss common cutaneous syndromes, such...

...parenteral options for systemic therapy currentl...

...maximize effectiveness and to min...

...ors that should be considered when select...

...inical Setting...

...therapy is preferred for treatment of...

39. Eschar(s) overlying ulcers should be...

...esponse Assessme...

...se to treatment is assessed by clinical criteria....

...Persons with CL should have their skin lesions...

...reatment Fail...

...al therapy is recommended (but not n...

...Consultation with a leishmaniasis expert abo...


...linical Characteristics of Cutaneous Leish...


Mucosal Leishmaniasis...

44. All persons with clinically manifest,...

...ore treatment is initiated, a complete examinat...

...6. The Panel recommends inpatient...

...hoice of antileishmanial agent, dose, and durat...


...sceral Leishmaniasis (V...

...ally life threatening and requires prompt e...

...The Panel recommends that persons with clinical ab...

...ggests that clinicians closely moni...

...For an immunocompetent person with VL,...

...an immunocompetent person with VL caused by...

...nt antimonial therapy (20 mgSbV/kg/day IV or...

...he Panel does NOT recommend switchi...

...onse Assessme...

...inical parameters correlate well w...

...rasitologic confirmation of response (such...

...reatment Fail...

...mpetent persons with VL who do not r...

...unocompetent persons with VL who do not...

...Immunocompetent persons with VL who respond...

...9. Combination therapies may be considered but...

...munocompromised Hosts...

...these guidelines, immunocompetent VL refers...

...Liposomal amphotericin B (L-AmB) is...

...therapy (eg, L-AmB plus miltefosine) mig...

...ons, antiretroviral therapy (ART) should be...

...ishmania infection that becomes clinical...

64. The Panel recommends administering secondary...

...ersons with VL-HIV/AIDS coinfection should be m...


...ASSOCIATED CL or ML in North A...

...In HIV/AIDS-associated CL/ML, systemic anti...

...ic regimens used for CL/ML in otherwise compar...

...etroviral therapy (ART) should be initiated or...


...ocompromised Hosts With Solid Organ Transplant, Pe...

...photericin B (L-AmB) is recommended as...

70. Doses of immunosuppressive drugs shoul...

...condary prophylaxis is NOT recommended for...

...serologic screening of organ donors from leishman...

.... The Panel suggests that clinicians N...

...suppressed persons with VL who are not coinfe...

...5. Confirmed VL therapeutic failure...

...el suggests that CL/mL associated with...


...al Populations...

77. In general, clinically manifest cases of...

...s regarding whether and how to treat cases of CL...


...shmaniasis Reference Diagnostic Laboratories...


...ch to Syndromic Treatment of Cutaneous Lei...


...ach to Syndromic Treatment of Mucosal Leishmaniasi...


...able 3c. Approach to Syndromic Treatment of Visc...


...otes for Tables 3a, 3b & 3c For simplic...


...Drugs Used in North America for Systemica Anti...