Leishmaniasis Kala azar and other forms Nedim akr

Leishmaniasis (Kala azar and other forms) Nedim Çakır Neu-med.

Etiology • A protozoan disease caused by Trypanasomidae family • Twenty of total 30 species may cause diseases in mamalians • Last classification CAKIR: LEISHMANIASIS 2014 -2015 2

Etiology-2 • Human cutaneous – mucucutaneous leishmaniasis : 1. L. braziliensis complex : L. braziliensis, L. panamensis/ L. guyanensis, L. shawi and L. Peruviana 2. L. mexicana complex: L. mexicana, L. amazonensis, L. Venezuelensis, L. lainsoni, L. Naifi ve L. lindenbergi. 3. L. tropica complex: L. tropica, L. anmd. L. aethiopica, • Human visceral leishmaniasis agents: – Leishmania donovani (includ. L. archibaldi’yi) and L. infantum/ L. chagasi CAKIR: LEISHMANIASIS 20142015 3

Etiology-epidemiology • Old World: L. İnfantum • New World: L. chagasi • Bu iki son etken eskiden ayrı türler gibi kabul edilmişse de yapılan analizlerde bunların tek tür oldukları anlaşılmıştır • L infantum may cause also cutaneous form without systemic infection CAKIR: LEISHMANIASIS 20142015 4

Global epidemiology-1 • All over the world except Australia, Oceania, Pasific Isld. s • Hyperendemic areas: Afghanistan, Brasil, Sudan CAKIR: LEISHMANIASIS 20142015

Global epidemiology-2 Most of patients (90 %) • Visceral form: Bangladesh, Basil, India, Nepal and Sudan • Muco-cutaneous form: Bolivia, Brasil, and Peru • Cutaneous form : Afghanistan, Brasil, Iran, Peru, Saudi Arabia, Syria • Mainly undeveloped countries and areas • In 33/88 countries unreported/ CAKIR: LEISHMANIASIS 20142015

Global epidemiology-3 • Totally 350 million patients • 350 million people are at risk worldwide (in six countries: Bangladesh, Ethiopia, Brazil, India, South Sudan and Sudan) • 12 Milionnew cases every year • Equal in rural and urban areas • HIV co-infections are at higher severity risk CAKIR: LEISHMANIASIS 20142015

Transmission: • Via biological vectors: – Phlebotomus and – Lutzomyia, • Each leishmania species adoptto and can survive in few phlebotomus species • Only female phlebotomus are responsible from transmission • Effect of seasonal conditions: – – Dry and windless seasons, Higher humidity Time: Dawn and evening hours Daytime: If they were disturbed in their hollow CAKIR: LEISHMANIASIS 20142015 8

Vector • Female phlebotomiade members ♀ – Old world Phlebotomus papatasi – New world Lutzomyia ♀ Lutzomyia mignoei Vector of L infantum CAKIR: LEISHMANIASIS 2014 -2015 ♂

Transmission: • Natural habitat: – Daytime • Animal shelters • Tree hollows, • evlerin görece serin ve nemli yerleri – Nighttime • Lighting attracts • Mechanical vectors: – Ticks(Dermacentor variabilis and Rhipicephalus sanguineus), dog’s flea • Dother transmission routes: – Asymptomatic individuals, – Blood transfusions, – Transplacental route (Vertical transmissions): Dogs, rats, and humans, Dog’s urine, tear, saliva or other secrets like semen, – Dogfights or dog lickings may responsible to transmissions l CAKIR: LEISHMANIASIS 20142015 10

L infantum amastigotes in dog macrophages CAKIR: LEISHMANIASIS 20142015 11

Lifecycle of leishmaniasis CAKIR: LEISHMANIASIS 20142015 12

Life cycle of Leishmania-1 Two stages have been detected: • Promastigot stage: Flagellated. . In vectors gut • Amastigot stage: Seen in mammary cells as intracellulary form • Only female Phlebotoms can transmit promastigots by biting • Parasites engulfed by macrophages and dendritic cells in dermis CAKIR: LEISHMANIASIS 20142015 13

Life cycle of Leishmania-2 • Losts flagels within dendritic cells amastigot form • Engulfed parasite remains alive in phagolysosomes • İnvades lymphatic and vasculary tissues • İnvades mocytic anda macrophages in RES Bone marrow infiltration, heptomegaly, splenomegaly, lymphadenopathy, CAKIR: LEISHMANIASIS 20142015 14

Epidemiology of VL • L. infantum infections Mainly immune deficient patients and infants • L. Donovani All ages • Global epidemiology: Yearly – 500, 000 new cases – 50, 000 death • The second most important parasitic infection after malaria CAKIR: LEISHMANIASIS 20142015 15

Epidemiolgy of L donovani, L infantum and L chagasi CAKIR: LEISHMANIASIS 20142015 16

Layşmanyoz klinik epidemiyolojisi CAKIR: LEISHMANIASIS 20142015 17

CAKIR: LEISHMANIASIS 20142015

Clinical picture of Leishmaniasis CAKIR: LEISHMANIASIS 20142015

Layşmanyoz klinik tipleri • Cutaneous (Dermal leishmaniasis) (CL) – – Localised cutaneous leishmaniasis (Oriental sore, Şark çıbanı) Diffuse cutaneous leishmaniasis Leishmaniasis residivans Post kala azar dermal eishmaiasis (PKDL) • Mucocutaneous leishmaniasis (MCL) • Visceral leishmaiasis (Kala azar) (VL) • Viscerotropic leishmaiasis (VTL) CAKIR: LEISHMANIASIS 2014 -2015 20

Cutaneous leishmaniasis • Dermal involvement • Single lesion multiple (Dozens) • Appearance of lesion: Depend upon the clinical types – – Ulcers, Nodules, Düz plaklar veya hyperkeratotic wart-like lesions CAKIR: LEISHMANIASIS 20142015

CL (Şark çıbanı) • Initial lesions: Papule at phlebotomus bite site • Lesions can remain antry-sites (Not as a rule) • Secondary lesions: – Lymphatic involvement – Skin and mucosal involvement – Secondary lymphanenopathy • Characteristics of cutaneous lesions: – Painless – Secondary lesions can be painful – Generally painful if auricular lesions – Mainly no subcutaneous incolvement – Outcome: – Spontaneous recovery depend upon clinical pictures – Few months few years – Some forms remain in permanent scars (oriental sore) • Severe clinical forms: – HIV co-infections – Other immune deficiency patients CAKIR: LEISHMANIASIS 2014 -2015

Cutaneous leishmaniasis (Oriental sore: Şark çıbanı) CAKIR: LEISHMANIASIS 2014 -2015

Orld World cutaneous leishmaniasis: ORİENTAL SORE ŞARK ÇIBANI CAKIR: LEISHMANIASIS 2014 -2015

CL: Disseminated form • Fairly seldom • Seen in : – L. amazonensis infections • More frequent in New World – Esatern hemisphere: • in HIV coinfections • İmmune deficiency CAKIR: LEISHMANIASIS 2014 -2015

Diffuse cutaneous leishmaniasis(DCL): • In L aethiopica/mexicana komplex infections • Chronic, prgressive, anerjiic variant • Nodules cannot turn ulcerative forms • Invades skin. • Deep tissues invasion also • Resistant to treatment CAKIR: LEISHMANIASIS 2014 -2015

Leishmaniasis rezidivans (Lupoid leishmaniasis) (LR): • L tropica and L braziliensis • After recovery of primary lesions • As satellite lesions around recovered cutaneous form • No spontaneous recovery. CAKIR: LEISHMANIASIS 2014 -2015

Mucocutaneous llwishmaniasis (Espundia) (MCL): • Most patient from Latin America • Agent(s): – L. braziliensis (generally) – L. panamensis/ L. Guyanensis (seldomly) • Due to extension of local skin disease into the mucosal tissue via – direct extension, – bloodstream or – lymphatics. • Appearance of syptoms: – Few years after healing of CL – Sometimes together Epistaxis • Initial lesions: – Hyperemia around nostrils CAKIR: LEISHMANIASIS 20142015

Mucocutaneous llwishmaniasis (Espundia) (MCL)(Cont’d) • Clinical pictures: – – – – Inflamation Tissue destruction İnvades to nasal septa Pharyngeal and/or laryngeal invasion Septal perforation Malformations (Papağan gagası, deve burnu görünümü) Obstruction of pharynx and/or larynx Rarely invasion of genitalia • No spontaneous healing, Patients need treatment CAKIR: LEISHMANIASIS 20142015

CAKIR: LEISHMANIASIS 2014 -2015

Visceral Leishmaniasis (VL) Kala azar Dum fever CAKIR: LEISHMANIASIS 2014 -2015

Clinical signs: General • Incubation period: 2 -6 mo. • Persistant systemic signs: Fever, malaise, fatigue, loss of apetite • Organomegaly: – Hepatomegaly – Splenomegaly • Other RES involvement: lymphatic CAKIR: LEISHMANIASIS 2014 -2015 32

Other caharacteristics of VL • Agent(s): Leishmania donovani complex • May fatal if not treat • Systemic symptoms • Leishmania infantum: Common in TRNC and Middle East Europe- North. Africa, and Latin Americada CAKIR: LEISHMANIASIS 20142015 33

Other caharacteristics of VL(Cont’d) Clinical types of VL Zoonotic VL (ZVL): • – – – • Reservoir: Animals Vector: Phlebotom Life cycle : Animals – Phlebotom - Humans Anthroponotic VL (AVL): – – – Reservoir: Humans Vector: Phlebotom Life cycle: humans – Phlebotom - Humans CAKIR: LEISHMANIASIS 20142015 34

ZVL – AVL: Epidemiologic characteristics • In Past: Genrally ZVL Seldomly AVL • Nowadays: ZVL-AVL Common • Günümüzde etken frkları – L infantum: Still ZVL – L donovani: AVL biçiminde bulaşır CAKIR: LEISHMANIASIS 20142015 35

Visceral leisahmaniasis: (VL) • Patinets from endemic area – Insidious onset and turn to chronic phase • Patients from non-endemic area and history of endemic area visits – Acute onset • In some African cases dermal granulomas can be detected • Clinical picturee: – – – Persistant intermittent fever, Weigh loss, Loss of apetite, Anemia, Abdominal discomfort Hepato-splenomegaly CAKIR: LEISHMANIASIS 20142015

Causes of anemia in VL • Persistan inflamatory stage • Hipersplenism • Bleedings CAKIR: LEISHMANIASIS 20142015 37

VL • Thrombositopenia: Petechia hemorrhage or mucosal bleeding • Leucopenia: Secondary infections • Other findings: Cough, chronic diarrhoea, skin hyperpigmentation, lymphadenopathychronic renal involvement • Mild clinical forms can heal spontaneously. • Untreated cases: secondary complications fatal outcome • Fulminant and fatal cases: – In HIV Co-infections • Asymptomatic infections: – Some patints may present live parasite despite adequate treatment – Asymptomatic carrier state + Immune defficiency

Kala azar pentade 1. Fever 2. Weigh loss 3. Organomegalies: Soft and palpable 4. Pansitopenia Severe thrombocytopenia epistaxis, petechias 5. Hypergamaglobulinemia CAKIR: LEISHMANIASIS 20142015

Geographic varations of VL’s clinical pictures Clinical findings can be changed due to geographic area • Lymphadenopathy: – Seldom in India – Frequent in Sudan • Dermal hyperpigmentation – Frequent in India – Only during prolonged infections in other endemic regions • Conclusion: Regional symptomatic varaiations should be determined by authorities CAKIR: LEISHMANIASIS 20142015 40

Outcome of VL • Splenomagaly may increase in delayed phase • Abdominal symptoms: – Abdominal swelling – Gastric pain – Hepatomegaly • Bacterial co-infections: Pneumonia, diarrhoea, activation of tuberculosis • Untreated patients: – Primary outcomes: – Secondary infections: Bacterial co-infections Few weeks – few months CAKIR: LEISHMANIASIS 20142015 41

VL’de epidemic polymorphism No relations between contamination and (Apparent, clinical) infection. . . ( Rate is not 1: 1) • Asymptomatic infection: Apparent infection rates – – – Sudan 1: 2, 62 11: 1’e Kenya: 4: 1 Etiopia 5, 6: 1 Iran 13: 1, Brasil 8: 1 18: 1 Spain 50: 1 • Q: Why are immunisation programs unsuccesful for some persons ? • Q: Why are there a difference between contamination and infection? Neden her etkeni alan hastalanamaz? • A: Host-spesific cellulary immunity has great effect on clinical pictures CAKIR: LEISHMANIASIS 2014 2015 42

Post-kala azar dermal leishmaniasis (PKDL): • • Etiology: L. donovani After recovery of VL In some patients Peri-oral area – Maculopapullary, – Macular or – nodullary rashes • African patient • Can be seen in. . . – 6. moths – Spontaneus healing even if not trated – Successful treatment cannot prevent PKLD CAKIR: LEISHMANIASIS 20142015

(PKDL) • One of complication of VL • Common in Sudan • Less frequent in other Eastern African countries and Indian subcontinent • Immuncompromised patients in L infantum endemic area • Very contagious vivid parasites present in nodulary lesions CAKIR: LEISHMANIASIS 2014 -2015 44

Genetic characteristics of tendency to VL • Severe T-cell irresponsiveless to L donovani antigens • İnterleucin 10 production , CD 25 -Foxp 3 that responsible to secret them • Concomitant diseases like Malnutrition and HIV that altered immun reactions • Others – Young ages – Diminished interferon-X production, – TNF –y gene-40 Promoter polymorfism • Controlling factors on macrophage activation: – Solute taşıcarrier gene family 11 A 1 (SLC 11 A 1; previously NRAMP 1) – Gene poliymorphism controls L 4 productions CAKIR: LEISHMANIASIS 20142015 45

Preventing strategies VL • Two control srategies : – Controlling of reservoir – Vector controll kontrolü • Immunisation programs still ongoing CAKIR: LEISHMANIASIS 20142015 46

Control of reservoirs • ZVL: L. İnfantum main reservoirs: Canines • Gradually ZVL decreases • Serologic sreening of canines ? ? • Treatment or killing the seropositive-animals ? ? • C 0 mments: – Animal treatment will not stop re-infections – Widely use of anti -ZVL drugs will cause resistant strains ilaçlarının yaygın kullanımı dirence yol açar • Protection of domerstic animals : Deltamethrin impregnated dogcollars – Prevention of animals from phlebotoms (54%) – Can be adopted to school collar stud: Prevents children: (43%)

Vector control • Insecticides : Effect, ve on Phlebotomes and pther mosquitos – Ör: DDT • Disadvantage: Repeated growth of mosquitos • resistance to insecticides İnsektis • Alternatives : DDT embedded nets CAKIR: LEISHMANIASIS 20142015 48

Early diagnosis and treatment: • Goal of early diagnosis and treatment: – Prevents new cases – Patient’s health – Prevention of AVL cases • Management of aditional problems: – Anemia, – Malnutrition – Treatmen of secondary infections CAKIR: LEISHMANIASIS 20142015 49

Diagnosis: Non-leishmanial tests • Pancytopenia (anemia, eucopeniai vehrombocytopenia) – Bu bulgunun özgünlüğü yüksek (%98) – Duyarlılığı düşük (%16) • Formol gel test (FJT) or aldehyde test: – Detects typical polyclonal hipergamaglobulinemias – Easy and chip – Low sensitivity (35%) CAKIR: LEISHMANIASIS 20142015 50

Diagnostic tests: Detection of parasytes • Direct diagnosis method by staining specimen: Amastigotes forms by direct staining methods – Len. Lymph nodes biposy, – Bone marrow – Splenic aspiration (Dangerous) • Evaluation of direct microscopy: – Highly spesific – Sensitivity • • Splenic aspiration: 93 -99 % Bone marrow aspirates: 53 -86% Lymph nodes biopsy: 53 -65% Attention to splenic sapirates by biopsy: May fatal results in ~ 0, 1 % May cause abundant bleeding • May need blood transfusiun and surgical support • Üculture methods: Highly sensitive – Culture parasytes itself – Detecting spesific gene areas by PCR CAKIR: LEISHMANIASIS 20142015 51

Culture methods • Culture in synthetic media • Culture media: – – – Novy-Mac. Neil-Nicole (NMN), Brain-Heart infusion (BHI), Evan’s modifiyed Tobie (EMTM), Grace Schneider’in Drosophila • Inoculation to hamsters: – If specimen is contaminated – If parasytes are very few • Time for test: 5 -30 days CAKIR: LEISHMANIASIS 20142015

Diagnosis: Antibody screening tests • Good antigenic in character May cause antibody tests possible • Validation of tests: – Satisfactory treatment may cause decreases in antibody levels – But not dissapears May detected few years • Interpretation Problems: – Definite diagnosis of relapses: İmpossible – Some symptomless and no clinical history persons who live in endemic area can be detected as «seropositive» • The standardization of tests are difficulte CAKIR: LEISHMANIASIS 20142015 53

Diagnosis: Antibody detecting tests • Methods: IFAT, Direct agglutination testi (DAT), immunochromatographic tests (ICT), Fast agglutination screening test(FAST) – DAT test: • Antigen Stained promastigotes • Spesificity and senstinity: over 90% • Validity: Geographic area and species of Leishmania canno affect results – FAST: Rapid agglutination test • 1/800 vand 1/1600 in dilution • Compleeted within 2 -3 hours Very applicative – ICT: method ELISA • Antigen r. K 39 Amino acid lines. . 39 aminoacidic chain • Excellent sensitivity(93– 100%) and spesificity (97– 98%) Widely used. . . CAKIR: LEISHMANIASIS 20142015 54

Diagnosis: Antigen detecting tests • Low false results • Latex agglutination: – Specimen: Urine – Saptanan antijen: Isıya dayanıklı ve küçük moleküllü karbonhidrat – Low sensitivity (48– 87%) – But correlation with treatment: Good (97– 100%) – False positivity: Should required boiling the test urine inorder to prevent false positivity – Weak positivity cannot be interpreted CAKIR: LEISHMANIASIS 20142015 55

Principles of visceral leishmaniasis treatment: General principles • Give spesific anti-leishmanial drugs • Consider other antiinfectives to treat superinfections • Antianemic drugs if anemia detected • Give parenteral liquids • Malnutrition CAKIR: LEISHMANIASIS 20142015 56

Spesific antileishmanial treatment: Pentavalent antimony compounds • Pentavalent antimony drugs were used for seventy years. – Meglumin antimonate or – Sodium stiboglukonat • Toxic in character. Side effects: – Severe arryhmia (can be mortral) – Acute pancreatitis • Slow effective: This can cause mortal risks – Infants less than 2 years old – Over adults over 45 – Patients who has severe malnutrition CAKIR: LEISHMANIASIS 20142015 57

Treatment • Anti-leishmanial drugs: Pentavalent Antimony comp. : – Sodium Stibogluconate: Pentostam (Britania) – Meglumine Antimonate: Glucantime (France) • 80 -100% • Similar effect CAKIR: LEISHMANIASIS 20142015

Second line treatment: Amfoterisin B • If antimony treatment failed • Side effects during the first line treatment – – • Chill, shivers Hypokalemia, Nephrotoxicity Anaphlaxy at during initial dose Liposomal amphotericin B – But expensive CAKIR: LEISHMANIASIS 20142015 59

Alternative treatment: Miltefosine • Primarily oncologic durg • Treatment rate: 82 %, • Side effects: – GİS complaints (rare) – Increase of creatinin – İncrease of AST and ALT • • Less effective in HIV co-infections Teratogenic effect No indication in pregnancy Serum half life: 150 hours Licenced animals(Dogs) leishmaniasis in Europe – some L infantum strains have miltefosin resistant CAKIR: LEISHMANIASIS 20142015 60

Alternative treatment: Paromomycin. . in combined treatment Paromomycin • Low toxicity and high safety – Ototoxicity – İncrease in liver enzymes • Monoherapy or combination with stibogluconate • Has also antibacterial effect Other combinations • Miltefosine + Liposomal amfotherycin B CAKIR: LEISHMANIASIS 20142015 61

Morbidity – mortality: • Temperate regions • Seasonal contaminations • In temperate months Mosquitos become active • • 1 -1, 5 million/year CL, 500. 000 VL cases Real amount? ? L. Donovani infect all ages group L. İnfantum – Healthy adults are more resistant – Asymptomatic infections are more frequent – Most cases are. . . • Childhood ages • Immuncompromised adults • Insufficient nutritions • Case/mortality rates untreated patients : 75– 95 % CAKIR: LEISHMANIASIS 20142015

References 1. http: //www. who. int/leishmaniasis/resources/documents/VL_NMR_1 107_ok. pdf 2. http: //www. cfsph. iastate. edu/Factsheets/pdfs/leishmaniasis. pdf 3. http: //www. who. int/leishmaniasis/resources/TURKEY. pdf 4. http: //leishinfonet. com/clinical. php Books 1. Chatterjee, K. D. (2009). Parasitology. New Delhi, CBS Publishers & Distributors PVT. LTD, pp. 64 -89 2. Cook, G. C. and Zumla, A. (2003). Manson’s tropical diseases, 21 st ed, Educational Low Priced Sponsored Texts. pp. 1339 - 1364. 3. Murray, H. W. , Berman, J. D. , Davies, C. R. and Saravia, N. G. (2005). Advances in leishmaniasis. Lancet, 366: 1561 -1577. CAKIR: LEISHMANIASIS 20142015