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
...iagnosis...
.... The Panel recommends using multiple diag...
...he Panel recommends attempting para...
...amplification assays typically should be performe...
.... Leishmania skin testing is NOT recommended...
.... The Panel suggests that identification...
...ssays should be performed, especiall...
...eous Leishmaniasis (CL)...
CL is the most common syndrome worldwid...
...issue specimens should be collected from a...
...Obtain a sample from a cleansed lesion...
...ologic testing is not recommended as part of the d...
...al Leishmaniasis (ML)
...ania species with an increased risk of caus...
...nitial and most prominent mucosal man...
...as that have macroscopic abnormalities are recomme...
...All persons at risk for ML—on the basis o...
...ing all evaluations (ie, initial and subseque...
...Persons at risk for ML should be e...
...risk for ML who have persistent mucosal symptom(s)...
...might refer some at-risk persons without doc...
...Leishmaniasis (VL)...
...tes (the tissue stage of the parasite) diss...
...recommends the collection of tissue aspirates or...
...aspiration is the preferred first source...
...9. Serum should be collected for detection of ant...
20. In immunocompromised persons,...
...c testing is recommended for persons with...
22. The Panel suggests that tests for antile...
Treatment
Treatm...
...aneous Leishmaniasis (C...
...mmendations for CL are not straightforward. M...
...careful diagnostic evaluation in which neither...
...The Panel recommends that immunocomp...
...For persons with CL when the Leishmania spec...
26. The Panel suggests that systemic treatment be...
...7. The Panel recommends that any decision to obs...
...In all cases of CL, wound care, individual...
...nadequate Treatm...
...tial consequences of inadequate treatm...
...rsons with CL should be actively monitored by...
.... Symptoms such as chronic nasal stuffiness...
...temic Treatm...
...atment is recommended for persons with comp...
...ial systemic therapy (see Recs. 35–...
...s common cutaneous syndromes, such as leishmaniasi...
...e parenteral options for systemic therapy...
36. To maximize effectiveness and to minimize...
...ctors that should be considered when sele...
...inical Settings...
...apy is preferred for treatment of OWCL lesio...
...Eschar(s) overlying ulcers should be debrided be...
...nse Assessment...
...o treatment is assessed by clinical criteria. Repe...
...ons with CL should have their skin lesio...
...tment Failure...
...therapy is recommended (but not nece...
...ation with a leishmaniasis expert about other trea...
Table 1. Clinical Characteristics of Cutaneo...
...ucosal Leishmaniasis...
...l persons with clinically manifest, metastatic, Am...
...eatment is initiated, a complete examinat...
...The Panel recommends inpatient monitori...
...he choice of antileishmanial agent, dose, and...
Visceral Leishmaniasis (VL...
VL is potentially life threatening and requires...
...l recommends that persons with clinical abnormalit...
...l suggests that clinicians closely mon...
...munocompetent person with VL, treatment...
51. For an immunocompetent person with VL c...
...ent antimonial therapy (20 mgSbV/kg/day...
...he Panel does NOT recommend switching to am...
...nse Assessment...
...rameters correlate well with parasitologic r...
...ogic confirmation of response (such as by r...
...tment Failure...
...unocompetent persons with VL who do no...
...Immunocompetent persons with VL who do...
...etent persons with VL who respond to initial...
.... Combination therapies may be cons...
...compromised Hosts
...guidelines, immunocompetent VL refers to...
.... Liposomal amphotericin B (L-AmB) is recommended...
...n therapy (eg, L-AmB plus miltefos...
...infected persons, antiretroviral ther...
...3. Leishmania infection that becomes...
.... The Panel recommends administering secondar...
...h VL-HIV/AIDS coinfection should be monitored in...
...DS-ASSOCIATED CL or ML in North America...
.... In HIV/AIDS-associated CL/ML, sy...
...e systemic regimens used for CL/ML in oth...
...oviral therapy (ART) should be initia...
Immunocompromised Hosts With Solid O...
...Liposomal amphotericin B (L-AmB) is recommended...
...unosuppressive drugs should be decreased...
...prophylaxis is NOT recommended for init...
...serologic screening of organ donors from leishman...
...anel suggests that clinicians NOT routin...
...pressed persons with VL who are not coinfected wit...
...VL therapeutic failure typically can b...
...Panel suggests that CL/mL associate...
...pecial Populat...
...clinically manifest cases of VL and mL should be...
...regarding whether and how to treat cases o...
...le 2. Leishmaniasis Reference Diagnostic...
...proach to Syndromic Treatment of Cutaneous Le...
...pproach to Syndromic Treatment of Mucosa...
.... Approach to Syndromic Treatment of Viscer...
...Tables 3a, 3b & 3c For simplicity, the...
...sed in North America for Systemica Antileis...