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...
...ecommends using multiple diagnostic approaches...
...anel recommends attempting parasite isolatio...
...cular amplification assays typically should be...
...kin testing is NOT recommended or available...
...anel suggests that identification of the infectin...
...A-based assays should be performed, especiall...
...eous Leishmaniasis (CL)...
...the most common syndrome worldwide and t...
...mens should be collected from a lesion(s...
...Obtain a sample from a cleansed lesion, fr...
9. Serologic testing is not recommended as part o...
...osal Leishmaniasis (M...
...species with an increased risk of causing...
...tial and most prominent mucosal manifestat...
...cosal areas that have macroscopic abnorma...
...ons at risk for ML—on the basis of the...
.... During all evaluations (ie, initial and subs...
...rsons at risk for ML should be educated and pro...
...5. Persons at risk for ML who have pe...
...Clinicians might refer some at-risk persons...
...l Leishmaniasis (VL)...
...L, amastigotes (the tissue stage of the parasit...
...ecommends the collection of tissue aspirat...
18. Bone marrow aspiration is the prefe...
19. Serum should be collected for detect...
...immunocompromised persons, blood should be colle...
...1. Serologic testing is recommended for p...
...nel suggests that tests for antileishmanial antibo...
Treatment
...eatment
...aneous Leishmaniasis (CL)
...ecommendations for CL are not straightfor...
...reful diagnostic evaluation in which neither lei...
...el recommends that immunocompetent persons with...
...with CL when the Leishmania species...
...nel suggests that systemic treatment be offered...
...The Panel recommends that any decision...
...all cases of CL, wound care, individu...
...nadequate Treatment
.... Potential consequences of inadeq...
...sons with CL should be actively monitored by c...
...h as chronic nasal stuffiness, epista...
...temic Treatment
...ic treatment is recommended for per...
...Initial systemic therapy (see Recs. 35–37) ma...
.... Less common cutaneous syndromes, s...
...The parenteral options for systemic th...
...mize effectiveness and to minimize toxicity,...
...should be considered when selecting CL treatment...
Clinical Setting...
...rapy is preferred for treatment of...
...s) overlying ulcers should be debrided...
...se Assessment...
...onse to treatment is assessed by clinical cr...
...Persons with CL should have their skin lesions...
...reatment Failur...
...tional therapy is recommended (but not nec...
...ion with a leishmaniasis expert about other tre...
...l Characteristics of Cutaneous Leishman...
...cosal Leishmaniasis (CL)
...with clinically manifest, metastatic, Ame...
...reatment is initiated, a complete exami...
...commends inpatient monitoring and prophylactic c...
...ice of antileishmanial agent, dose, and...
...isceral Leishmaniasis (VL...
...s potentially life threatening and requires p...
...recommends that persons with clinic...
...anel suggests that clinicians closel...
...an immunocompetent person with VL, treatment wi...
...or an immunocompetent person with VL caused by L...
...antimonial therapy (20 mgSbV/kg/day IV or...
...does NOT recommend switching to amphotericin B de...
...onse Assessment
...parameters correlate well with parasitologic...
...ogic confirmation of response (such as by rep...
Treatment Failure
...tent persons with VL who do not respond...
...competent persons with VL who do not resp...
...Immunocompetent persons with VL who respond to i...
...ombination therapies may be considered but have no...
...munocompromised Hosts
...lines, immunocompetent VL refers to pers...
...al amphotericin B (L-AmB) is recom...
...Combination therapy (eg, L-AmB plus mil...
...rsons, antiretroviral therapy (ART) should be...
...Leishmania infection that becomes clinica...
...Panel recommends administering secondary proph...
...Persons with VL-HIV/AIDS coinfection should be m...
...IDS-ASSOCIATED CL or ML in North Americ...
...S-associated CL/ML, systemic antileishmanial th...
...7. The systemic regimens used for CL/ML in...
...oviral therapy (ART) should be initiate...
...mpromised Hosts With Solid Organ Transplant...
69. Liposomal amphotericin B (L-AmB) i...
...munosuppressive drugs should be decre...
...ndary prophylaxis is NOT recommend...
...serologic screening of organ donor...
...ggests that clinicians NOT routinely perform...
...ppressed persons with VL who are not coinfected w...
...5. Confirmed VL therapeutic failure typ...
...Panel suggests that CL/mL associated...
...ial Population...
...neral, clinically manifest cases of VL...
...8. Decisions regarding whether and ho...
...shmaniasis Reference Diagnostic Laboratories in...
...le 3a. Approach to Syndromic Treatment o...
...oach to Syndromic Treatment of Mucosal Leishman...
...Approach to Syndromic Treatment of Viscera...
...ables 3a, 3b & 3c For simplicity, the termin...
...able 4. Drugs Used in North America f...