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

Diagnosis

...Panel recommends using multiple diagnostic a...

...ecommends attempting parasite isolation with the...

...plification assays typically should be performed b...

.... Leishmania skin testing is NOT recommended or a...

...ggests that identification of the infec...

6. DNA-based assays should be performed, esp...


...ous Leishmaniasis (CL)...

...common syndrome worldwide and the one most like...

...ssue specimens should be collected from a lesion...

...ample from a cleansed lesion, from wh...

...c testing is not recommended as part of t...


...l Leishmaniasis (M...

...ecies with an increased risk of causin...

...and most prominent mucosal manifestations...

...1. Mucosal areas that have macroscopic abnorm...

...ns at risk for ML—on the basis of the...

...evaluations (ie, initial and subsequ...

...at risk for ML should be educated...

...risk for ML who have persistent mucosal...

...ight refer some at-risk persons with...


...isceral Leishmaniasis (V...

...n VL, amastigotes (the tissue stage of the par...

...7. The Panel recommends the collection of t...

...one marrow aspiration is the preferred first s...

...9. Serum should be collected for detecti...

.... In immunocompromised persons, bloo...

...rologic testing is recommended for p...

22. The Panel suggests that tests for antile...


Treatment

...reatmen...

...ous Leishmaniasis (...

...recommendations for CL are not straightforward...

...careful diagnostic evaluation in which nei...

...he Panel recommends that immunocompetent perso...

...persons with CL when the Leishmania...

...nel suggests that systemic treatment be o...

27. The Panel recommends that any deci...

...ll cases of CL, wound care, individualized d...

...nadequate Trea...

...otential consequences of inadequate treatment...

...Persons with CL should be actively monitore...

...1. Symptoms such as chronic nasal stuffine...

...emic Treatment...

...reatment is recommended for persons with...

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

...ss common cutaneous syndromes, suc...

...e parenteral options for systemic th...

...ximize effectiveness and to minimize...

...ctors that should be considered when selecting C...

...inical Setti...

...py is preferred for treatment of OWCL lesions de...

...ar(s) overlying ulcers should be debrided b...

Response Asses...

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

...rsons with CL should have their skin lesions mo...

...reatment Failure...

...herapy is recommended (but not neces...

43. Consultation with a leishmaniasi...


...1. Clinical Characteristics of Cutane...


...ucosal Leishmaniasis (CL...

44. All persons with clinically ma...

...5. Before treatment is initiated, a complet...

...nel recommends inpatient monitoring and...

...he choice of antileishmanial agent, dose, an...


...eral Leishmaniasis (VL)...

...tentially life threatening and requires...

...nel recommends that persons with clinical abnormal...

.... The Panel suggests that clinicians clos...

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

...ocompetent person with VL caused by L. do...

...ent antimonial therapy (20 mgSbV/kg/day IV or I...

.... The Panel does NOT recommend switchin...

...onse Assessment

...linical parameters correlate well wi...

...ic confirmation of response (such as by repeat...

...tment Failur...

...6. Immunocompetent persons with VL who d...

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

...unocompetent persons with VL who respond to in...

...therapies may be considered but have not b...

...compromised Host...

...guidelines, immunocompetent VL refers to persons...

...posomal amphotericin B (L-AmB) is rec...

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

...d persons, antiretroviral therapy (A...

...ishmania infection that becomes clinically ma...

...4. The Panel recommends administering...

...ons with VL-HIV/AIDS coinfection s...


.../AIDS-ASSOCIATED CL or ML in North America

.../AIDS-associated CL/ML, systemic antileishmanial...

...The systemic regimens used for CL/ML i...

...roviral therapy (ART) should be initiated or op...


...ocompromised Hosts With Solid Organ Transp...

...l amphotericin B (L-AmB) is recommended...

...of immunosuppressive drugs should be decreased in...

.... Secondary prophylaxis is NOT recommended for ini...

...utine serologic screening of organ do...

...nel suggests that clinicians NOT routinel...

...pressed persons with VL who are not c...

...VL therapeutic failure typically can...

...anel suggests that CL/mL associated with the...


...ial Populations...

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

...ons regarding whether and how to t...


...e 2. Leishmaniasis Reference Diagnostic Laboratori...


...3a. Approach to Syndromic Treatment of Cu...


Table 3b. Approach to Syndromic Treat...


...ble 3c. Approach to Syndromic Treatment of Viscer...


...tes for Tables 3a, 3b & 3c For simp...


...4. Drugs Used in North America for...