Leishmania ,the parasite, Disease and Management

Zoonotic disease spread by sandfly. 21 species, 2 main subgenuses - Leishmania and Viannia

1. LEISHMANIA

2. INTRODUCTION Zoonotic 21 species – Pathogenic Visceral and Cutaneous 2 subgenuses – Leishmania , Viannia KALA AZAR – BLACK SICKNESS

3. INDEX H ISTORY T AXONOMY C LASSIFICATION E PIDEMIOLOGY M ORPHOLOGY L IFE C YCLE P ATHOGENICITY C LINICAL F EATURES L ABORATORY D IAGNOSIS T REATMENT P ROPHYLAXIS/ P REVENTIVE M EASURES L EISHMANIA C OINFECTIONS

4. HISTORY Cutaneous leishmaniasis (CL) – King Ashurbanipal from the seventh century BC Physicians (10th century AD)  Balkh sore  15th and 16th century Spanish colonials "valley sickness", "Andean sickness", " white leprosy”  1756, Alexander Russell, gave detailed clinical description  Indian doctors pronounced it kālā āzār   Hindustani phrase for "black fever”

5. 1901, Leishman  identified organisms from spleen of a patient dead from "dum-dum fever" -  in Calcutta , India Captain Charles Donovan  (1863–1951) confirmed Leishman -Donovan bodies - Madras, India. Ronald Ross proposed - name  Leishmania donovani

6. TAXONOMY Phylum Subphylum Class Order Family Genus Sarcomastigophora Mastigophora Zoomastigophorea Kinetoplastida Trypanosomatina Leishmania

7. CLASSIFICATION Species Classification based on Isoenzyme analysis DNA sequence analysis Antigenic structure Biochemical properties Growth properties Clinical Classification based on Site The geographical distribution

8. LEISHMANIA Leishmania Leishmania donovani complex Viannia Leishmania dononvani Leishmania chagasi Leishmania infantum Leishmania archibaldi Leishmania tropica complex Leishmania major complex Leishmania aethiopica complex Leishmania mexicana complex Leishmania guyanensis complex Leishmania braziliensis complex Leishmania lainsoni complex Leishmania naiffi complex Leishmania tropica Leishmania mexicana

9. CLINICAL CLASSIFICATION MUCOCUTANEOUS LEISHMANIASIS VISCERAL LEISHMANIASIS ( KALA AZAR) CUTANEOUS LEISHMANIASIS Indian Kala Azar (L. donovani ) Mediterranean Kala Azar (L. infantum ) South american Kala Azar (L. chagasi ) African Kala Azar ( L.archibaldi ) South America L. braziliensis NEW WORLD L.mexicana , L.braziliensis OLD WORLD L.tropica , L.major , L.aethiopica Dermal Leishmnoid (PKDL )

10. EPIDEMIOLOGY Worldwide prevalence 12 million cases Population at risk is about 350 million. Endemic countries 88 90 % of cases with Cutaneous Leishmaniasis occur in Afghanistan, Algeria, Brazil, Iran, Peru, Saudi Arabia and Syria Ninety per cent of Visceral Leishmaniasis cases are found in Bangladesh, Brazil, India, Nepal and Sudan

11. W ORLDWIDE D ISTRIBUTION O F L EISHMANIASIS   http://www.geo.arc.nasa.gov

12. EPIDEMIOLOGY IN INDIA 165 million people estimated to be at risk BIHAR state is the worst affected West Bengal ten districts affected Jharkhand five districts and Uttar Pradesh with four districts

13. EPIDEMICS Sudan a major epidemic of visceral leishmaniasis occurred from 1984 to 1994  Kabul in 2002 Pakistan in 2004 , Sudanese refugee camps , Chad in 2007. Ethiopia (2005–06), Kenya (2008), and Southern Sudan (2009) In India last major outbreak was reported around 1944 from Assam ( 1995  Outbreak of kala-azar in Bombay)

14. LEISHMANIA DONOVANI 1903 Endemic – India , China, Africa Intracellular in Man Amastigote form RE system

15. MORPHOLOGY Two stages : Amastigote Stage : Man Promastigote Stage : Sandfly , Artificial culture Amastigote Stage ( Aflagellar ) Round /oval (2-4µ) Cell membrane present only in FRESH specimens Nucleus ‹ 1µ Kinetoplast lies tangentially to nucleus Axoneme ( extension from kinetoplast to margin of body) Vacuole surrounds Axoneme LEISHMAN DONOVAN (LD) BODIES

16. Promastigote Stage ( Flagellar ) Initial …Pear shaped 5-10 µ length and 1- 5µ in breadth Later ….Spindle shaped 15-20µ by 1-2µ Nucleus is central Kinetoplast transverse , anterior Flagellum : anteriorly placed

17. PROMASTIGOTES AMASTIGOTES

18. SAND FLY Subfamily  Phlebotominae ( argentipes - India)   In the  New World , leishmaniasis is spread by sand flies of the genus  Lutzomyia In the  Old World , the disease is spread by   Phlebotomus Female  1.5–3 mm, yellowish in colour (hairy body, wings and legs) Wings are oval lanceolate Females Haematophagus , Males sap feeders

19. MAMMALIAN HOSTS Rodents L. archibaldi , L.major Dogs L. infantum , L. chagasi , L.tropica Foxes L. infantum ,L. chagasi Humans L. donovani , L.tropica Gerbil L.major

20. LIFE CYCLE BLOCKED

21. PATHOGENESIS Incubation Period : 3-6 months Inoculation of Promastigotes in skin Ingestion of Promastigote by Neutrophils Attraction of macrophages Ingestion of infected neutrophil, Amastigote formation (Macrophage) Invasion by Plasma cells and lymphocytes Amastigotes liberated in circulation after rupture RE cells proliferate, heavily parasitised

22. CLINICAL DISEASE Visceral Fatal (90% untreated) Liver Spleen RE Bone marrow Cutaneous Generally Self- healing Skin Mucous membranes

23. VISCERAL LEISHMANIASIS Low grade fever continuous / intermittent Hepato-splenomegaly RE system affected Bone marrow hyperplasia Anemia , Leucopenia Hypergammaglobulinnemia Epistaxis , Proteinuria , Hematuria If left untreated ....Fatal 75-95%

24. A 12-year-old boy suffering from visceral leishmaniasis . The boy exhibits splenomegaly and severe muscle wasting.

25. Profile view of a teenage boy suffering from visceral leishmaniasis .

26. COMPLICATIONS Amoebic/ Bacillary dysentry Pneumonia / Tuberculosis Cancrum oris (extreme neutropenia ) Sepsis Death (untreated)

27. LABORATORY DIAGNOSIS KALA AZAR : DIRECT EVIDENCE ( Demonstration of L.donovani ) INDIRECT EVIDENCE

28. DIRECT EVIDENCE PERIPHERAL BLOOD BY THICK FILM METHOD ( Amastigote form/ LD bodies) Leishmans stain / Giemsa stain Positivity rate is low – Centrifuge Peripheral smear : Mononuclear leucocytes Buffy Coat : Neutrophils BIOPSY MATERIAL : Lymph node puncture Sternal / Iliac crest puncture 50-85 % Positive, Safe * Spleen puncture * 98 % Positive; Risky

29. Blood Culture : Novy Mac Neal, later modified by Nicolle (N.N.N.)medium ( 2 parts of salt agar , 1 part defibrinated Rabbit blood, Ascorbic acid and Haematin ) Specimen inoculated in water of condensation 22°C – 24°C, 4 weeks Promastigote Form Least sensitive, Long time

30. LEISHMANIA DONOVANI - AMASTIGOTES - HUMAN LIVER

31. INDIRECT EVIDENCE Blood count : Neutropenia, Anaemia , Relative Lymphocytosis Serological Tests : Aldehyde ( Formal gel) Test (Napier) To detect gamma globulin Antimony test : Increase in globulin levels ( Not used now) Complement Fixation Test : Utilises W.K.K. antigen ( Witebsky , Klinenstein and Kuhn ) Early diagnosis ( Not used now )

32. Other serological tests : ELISA , Latex particle agglutination, CIE, IFA Ig G Ab detection Molecular diagnosis : PCR , Western Blot - CHOICE

33. DIRECT AGGLUTINATION TEST (DAT) Semi-quantitative test Microtitre plates : increasing dilutions of patient's serum or blood is mixed with stained killed  L. donovani promastigotes . Agglutination visible after 18 hours  A titre greater than 1:3200 is positive

34. TREATMENT VISCERAL LEISHMANIASIS : Aggressive management of associated bacterial or viral infections, anaemia , hypovolemia and malnutrition. Sodium Stibogluconate 20 mg/kg/day for 30 days Miltefosine 2.5 mg/kg/day for 28 days. Cure rate is 94% Second line: Liposomal Amphotericin B, 1 mg/kg/day for 15 days.

35. POST KALA AZAR DERMAL LEISHMANOID (PKDL) Normally develops <2 years after recovery from VL(10-20%) L.donovani Non ulcerative Restricted to skin India ...Bengal & Assam , Africa Clinical Presentation Macular and hypopigmented , Erythematous patch Nodules Treatment : Pentavalent antimonials

36. CUTANEOUS LEISHMANIASIS "Aleppo boil," "Baghdad boil," "Bay sore," " Biskra button," " Chiclero ulcer," "Delhi boil," "Kandahar sore," "Lahore sore," " Leishmaniasis tropica ," "Oriental sore," " Pian bois," and " Uta " BISKRA BUTTON UTA

37. A raised, red nodule develops at site of bite Central crust Ulcerative lesion or Dry scales Old World (OWCL) Anthroponotic / Urban Cutaneous Leishmaniasis (ACL) L.tropica : self healing with scarring Zoonotic /Rural Cutaneous Leishmaniasis (ZCL) L.major : painless lesions, rapid self healing ( Non immune person – scarring) Diffuse cutaneous leishmaniasis (DCL ) L. aethiopica : diminished cell mediated - disfiguring nodular lesions New World (NWCL) Bay sore : L.mexicana , Uta : L.peruviana

38. (MCL) L.braziliensis Central and South america 2 Stages Primary cutaneous lesion Secondary mucosal lesion 5% cases Nasal septum is destroyed Lymphatic / Hematogenous spread Death due to respiratory distress

39. TREATMENT CUTANEOUS LEISHMANIASIS : Intralesional antimonials ,   Fluconazole 200-400 mg daily Rifampicin Cryosurgery Radiofrequency heat therapy

40. PREVENTION STRATEGY FOR CONTROL    1. Interruption of transmission by reducing vector population through indoor residual insecticides (DDT) 2. Early diagnosis and complete treatment of Kala- azar cases 3. Health education programme for community awareness

41. LEISHMANIA /HIV COINFECTION Since 1990, cases of co-infection have been reported from 34 countries worldwide 70 % reported in South-Western Europe V.L is MC associated with HIV CD4 < 200cells/mm Mode of transmission IV drug users 60-70 % Europe ; 15 % rest In India HIV- Leishmania co-infection is estimated to occur in less than 1% of patients

42. The triad of HIV, tuberculosis and VL has been reported ( Pandey et at, 2005). Poverty, overcrowding, malnutrition, polygamy, illiteracy, and poor domestic conditions facilitate the growth of these diseases The Mantoux test / Purified protein derivative test : Negative in HIV infection Hence ELISA and PCR ( utmost importance ) Both visceral leishmaniasis (VL) and tuberculosis (TB) increasing in Sudan Mycobacteria / Leishmania share common Antigen LEISHMANIA / TUBERCULOSIS COINFECTION

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