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
...Diagnosis...
...The Panel recommends using multiple diagnosti...
...recommends attempting parasite isolation with...
...ecular amplification assays typically s...
...eishmania skin testing is NOT recommended or av...
...Panel suggests that identification...
...based assays should be performed, especi...
...Cutaneous Lei...
...is the most common syndrome worldwide and t...
.... Tissue specimens should be collected...
...a sample from a cleansed lesion, from which ce...
...gic testing is not recommended as part of...
...Mucosal Leishmaniasi...
...mania species with an increased risk o...
...The initial and most prominent mucosal manifest...
...eas that have macroscopic abnormalities are recom...
...persons at risk for ML—on the basis...
...g all evaluations (ie, initial and...
...s at risk for ML should be educate...
...ons at risk for ML who have persistent mucosal s...
...ans might refer some at-risk persons withou...
...Visceral Leishmani...
...amastigotes (the tissue stage of the parasi...
...recommends the collection of tissue aspira...
18. Bone marrow aspiration is the pr...
...rum should be collected for detect...
20. In immunocompromised persons, bl...
...gic testing is recommended for per...
...el suggests that tests for antileis...
Treatment
Tre...
...Cutaneous Leishmania...
...ment recommendations for CL are not straightfo...
...careful diagnostic evaluation in which neither...
...recommends that immunocompetent persons...
...persons with CL when the Leishmania...
...The Panel suggests that systemic treatmen...
...The Panel recommends that any decision to observe...
...all cases of CL, wound care, individualized...
...Inadequ...
...tential consequences of inadequate...
...0. Persons with CL should be actively monitore...
...ymptoms such as chronic nasal stuffiness,...
...Systemic Treatmen...
...reatment is recommended for persons with comple...
...stemic therapy (see Recs. 35–37) may be used...
...cutaneous syndromes, such as leishmaniasis reci...
...The parenteral options for systemic th...
...6. To maximize effectiveness and to minimize...
...ctors that should be considered when sele...
...Clinical...
...y is preferred for treatment of OWCL lesions...
...erlying ulcers should be debrided be...
...Response...
...se to treatment is assessed by clinical...
...with CL should have their skin lesions m...
...Treatment Failure...
...nal therapy is recommended (but not necessari...
...ltation with a leishmaniasis expert about ot...
...able 1. Clinical Characteristics o...
...Mucosal...
...l persons with clinically manifest, m...
...efore treatment is initiated, a comp...
...commends inpatient monitoring and...
...hoice of antileishmanial agent, dose, and duration...
...Visceral Leishma...
...y life threatening and requires prompt evaluation...
...anel recommends that persons with clinical a...
.... The Panel suggests that clinicians clos...
...an immunocompetent person with VL, trea...
...immunocompetent person with VL caused...
...Pentavalent antimonial therapy (20 mg...
.... The Panel does NOT recommend switching...
...R...
...rameters correlate well with parasitologic resp...
...sitologic confirmation of response (s...
...Trea...
...munocompetent persons with VL who do n...
...munocompetent persons with VL who d...
...Immunocompetent persons with VL who resp...
...ombination therapies may be considered but have...
...Immunocomp...
...idelines, immunocompetent VL refers...
...mal amphotericin B (L-AmB) is recomme...
...tion therapy (eg, L-AmB plus miltefosi...
...sons, antiretroviral therapy (ART) should...
...a infection that becomes clinically man...
...nel recommends administering secondar...
.... Persons with VL-HIV/AIDS coinfection should be...
...HI...
...associated CL/ML, systemic antileishmanial thera...
...e systemic regimens used for CL/ML in othe...
.... Antiretroviral therapy (ART) should...
...Immun...
69. Liposomal amphotericin B (L-AmB) is recommend...
...es of immunosuppressive drugs shoul...
...ary prophylaxis is NOT recommended for in...
...serologic screening of organ donors from...
...e Panel suggests that clinicians NOT routinel...
...4. Immunosuppressed persons with VL...
...onfirmed VL therapeutic failure typically can be...
.... The Panel suggests that CL/mL associated with...
...S...
...clinically manifest cases of VL and mL sh...
...egarding whether and how to treat cases of CL in...
...e 2. Leishmaniasis Reference Diagnostic Labor...
...le 3a. Approach to Syndromic Treatment...
...ble 3b. Approach to Syndromic Treatme...
...roach to Syndromic Treatment of Visceral Leishm...
...otes for Tables 3a, 3b & 3c For simp...
...able 4. Drugs Used in North America f...