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
Diagnosi...
...The Panel recommends using multiple diagnosti...
...anel recommends attempting parasite isolation...
...Molecular amplification assays typically should b...
...Leishmania skin testing is NOT recommended or...
...Panel suggests that identification of th...
...assays should be performed, especially if other...
...eous Leishmaniasis (CL)...
...the most common syndrome worldwide and the one mo...
...pecimens should be collected from a lesion(s) whe...
...btain a sample from a cleansed lesion,...
...ting is not recommended as part of the diagn...
Mucosal Leishmaniasis (ML...
...ecies with an increased risk of causing mucosal...
...itial and most prominent mucosal manife...
...ucosal areas that have macroscopic abnormalities...
...ersons at risk for ML—on the basis of th...
...all evaluations (ie, initial and su...
...risk for ML should be educated and provided...
...ons at risk for ML who have persistent mucosal s...
...ians might refer some at-risk persons without...
...Leishmaniasis (VL)...
...VL, amastigotes (the tissue stage of the...
...e Panel recommends the collection of...
.... Bone marrow aspiration is the preferred f...
...should be collected for detection of antileish...
...n immunocompromised persons, blood should be col...
...esting is recommended for persons with suspe...
...Panel suggests that tests for antilei...
Treatment
...eatment...
...taneous Leishmaniasi...
...recommendations for CL are not straightforwa...
...3. After a careful diagnostic evaluation in w...
...he Panel recommends that immunocompetent person...
...ons with CL when the Leishmania specie...
...e Panel suggests that systemic treatment be offere...
27. The Panel recommends that any deci...
28. In all cases of CL, wound care, individualiz...
...uate Treatment...
...9. Potential consequences of inadequate treatment...
...CL should be actively monitored by clinic...
...h as chronic nasal stuffiness, epistaxis,...
...emic Treatme...
...2. Systemic treatment is recommended...
...Initial systemic therapy (see Recs. 35...
...n cutaneous syndromes, such as leishmaniasis...
...e parenteral options for systemic therapy curr...
...mize effectiveness and to minimize toxicity,...
...rs that should be considered when selecting...
...linical Setting...
...8. Local therapy is preferred for treatment of...
...9. Eschar(s) overlying ulcers should...
Response Asse...
...treatment is assessed by clinical criteria....
...th CL should have their skin lesions monitored...
...tment Failure...
.... Additional therapy is recommended (but not ne...
...Consultation with a leishmaniasis expert about...
...cal Characteristics of Cutaneous Le...
...Leishmaniasis (CL)...
44. All persons with clinically manifest, metas...
...tment is initiated, a complete examination of th...
...anel recommends inpatient monitoring...
...The choice of antileishmanial age...
...isceral Leishmaniasi...
VL is potentially life threatening...
...he Panel recommends that persons with clinical ab...
...anel suggests that clinicians clos...
...For an immunocompetent person with VL, treatment...
...n immunocompetent person with VL caused by...
...alent antimonial therapy (20 mgSbV/k...
...3. The Panel does NOT recommend switching to amp...
...onse Assessmen...
...4. Clinical parameters correlate w...
...asitologic confirmation of response (suc...
...eatment Failure
...nocompetent persons with VL who do not re...
...munocompetent persons with VL who do not respond t...
...ent persons with VL who respond to initi...
...tion therapies may be considered but have not bee...
...munocompromised...
...guidelines, immunocompetent VL re...
...amphotericin B (L-AmB) is recommen...
...Combination therapy (eg, L-AmB plus milte...
...infected persons, antiretroviral therapy (ART)...
...nia infection that becomes clinically manifest o...
...anel recommends administering secondary pr...
...VL-HIV/AIDS coinfection should be monit...
...IDS-ASSOCIATED CL or ML in Nort...
...associated CL/ML, systemic antileishmani...
...The systemic regimens used for CL/ML in ot...
...troviral therapy (ART) should be initi...
...promised Hosts With Solid Organ Tr...
...photericin B (L-AmB) is recommended as the drug of...
...Doses of immunosuppressive drugs...
.... Secondary prophylaxis is NOT recommended for in...
...2. Routine serologic screening of organ d...
...The Panel suggests that clinicians NOT rout...
...Immunosuppressed persons with VL who...
.... Confirmed VL therapeutic failure typically can b...
...The Panel suggests that CL/mL associated with...
...cial Populations...
...In general, clinically manifest cases of...
...ions regarding whether and how to treat cases of...
Table 2. Leishmaniasis Reference Diagnostic Lab...
...a. Approach to Syndromic Treatment of Cuta...
...e 3b. Approach to Syndromic Treatment of Muco...
...able 3c. Approach to Syndromic Treatment of Vi...
...Tables 3a, 3b & 3c For simplicity, the termin...
...e 4. Drugs Used in North America for...