6Leishmania life cycleAmastigotes replicate in reticuloendothelial cells (mononuclear cells) including;MonocytesMacrophages in lymph nodes, spleen, and lung;Kupffer cells in sinusoids of liverMicroglial cells in the central nervous system.Dendritic cellsPromastigotes reproduce in biting fly (Phlebotomus, Lutzomyia)
8Leishmania infects and thrives in macrophages Promastigotes attached to CR1 and CR3 receptors on the macrophagesThe parasite invades its host cell passively by phagocytosis (parasitophorous vacuole)
9Leishmania sp. amastigote stage Ovoid small intracellular parasites in a bone marrow aspirate. The typical rod shaped kinetoplast is seen besides the nucleus.(Giemsa stain).
10Leishmaniasis vectors There are over 600 species of sand flies divided into five genera. More than 30 species are proved vectors.Phlebotomus in the Old-world and Lutzomia in the New world are vectors of human leishmaniasis.
11Procyclics and Metacyclic Promastigotes Amastigotes are released by digestion, transform into procyclic promastigotes and attach to the midgut epitheliumAttached promastigotes divide rapidlyMetacyclic (infective) promastigotes cease replication, detach and pass forward into the pharynx from where they are regurgitated into the bite site(detached)(attached)
12Two subgenera of Leishmania genus subgenus Leishmania: develops in the sand fly’s midgut and foregut (suprapylorian)Both Old world and New world visceral and cutaneous speciessubgenus Viannia: develops in the hindgut and midgut (peripylarian).L. braziliensis complex, L. guyanensis complex.
13ImportanceLeishmaniasis is a parasitic disease transmitted by the bite of sand flies.In at least 88 countries.350 million people at risk.12 million people are affected by leishmaniasis.1.5-2 million new cases of cutaneous leishmaniasis estimated to occur annually.new cases of VL which occur annually.90% of CL cases were from Afghanistan, Algeria, Brazil, Iran, Peru, Saudi Arabia and Syria.90% of VL cases were from Bangladesh, India, Nepal, Sudan and Brazil.90% of mucocutaneous leishmaniasis occurs in Bolivia, Brazil and Peru.
14Endemic areas for leishmaniasis Highlighted areas are parts of the world where leishmaniasis has been reported.Taken from British Medical Journal :378
15The disease main forms Cutaneous leishmaniasis (CL) 2. Visceral leishmaniasis (VL), (kala-azar) is the most severe form of the disease. Mortality rate 75-95%3. Mucocutaneous leishmaniasis (MCL), or espundia, disfiguring, destruction of mucous membranes of the nose, mouth and throat cavities. Reconstructive surgery of deformities is an important part of therapy
17Cutaneous Leishmaniasis Skin ulcers on the exposed parts of the body such as the face, arms and legs.Old World: L. major, L. tropica, L. aethiopica (DCL)New World: L. mexicana, L. pifanoi, L. amazonensis, L. venezuelensis, L. granhami,
18Cutaneous Leishmaniasis Characterized by one or more papules, nodules and sores on the skinSore like a volcano with a raised edge and central crater.Two figures including urban (dry) and rural (wet) forms.Sores are usually painless but can become painful if secondarily infectedchronic but self-limitingSome sores are covered by a scab or have not yet ulcerated so they may look like red raised plaques- sometimes with dry crust/scale
19Swollen lymph nodes may be present near the sores (under the arm if the sores are on the arm or hand…)The skin sores will heal by themselves, but this can take months or years. The sores can leave ugly scars.
20Infection remains restricted to the initial site of infection (the bite site)
22Leishmania tropica Anthroponotic Cutaneous Leishmaniasis (ACL) Definitive Host: Humans(occasionally dog?)Intermediate Host: Phlebotomus sand fliesMain vector and also in Iran: P. SergentiDry or urban C.L.Face> hand, leg and…Incubation period: 2-8 months(usually 2-3 months)Lesion persist for several months (more than one year) then person is immune
23Leishmania tropica First sign: small papule nodule dry sore Itching Sores don’t heal very quicklyOften mistaken for leprosy or tuberculosisFirst sign: small papule nodule dry soreItchingScar (if not treated)
24Upper Eyelid.Note the dry, crusted/scabbed appearance which is different than previous sores shown.Photograph provided by COL Naomi Aronson
25Rarely can cause visceral (viscerotropic) and diffuse cutaneous infections.
26Leishmania major Wet or rural form Definitive Host: rodents (Rodentia: Gerbillidae) as reservoir host, HumansIn Iran: Rhombomys opimus, Meriones libycus, M.hurrianae, Tatera indicaZoonotic Cutaneous leishmaniasis (ZCL)Intermediate Host: Phlebotomus sand flies.In Iran: P. papatasi.Incubation period: some weeks to 3 months ( usually 2 weeks)First sign: small papule nodule Wet sore (exudates)ItchingScar (if not treated)Disease period is usually short (2-8 months)More in hands and feet
28Both lesions are leishmaniasis Note the raised border and wet appearance of the sore on the back of the hand.Sores over joints are very concerning as scarring with healing can lead to limited movement of joint.Photograph provided by COL Charles Oster
30Sporotrichoid form:Dissemination of amastigotes via the lymphatics to the subcutaneous tissues.Regional lymphadenopathy with feverDifferent cases from Panama and Brazil. The main causative agents were L (V) panamensis and L (V) guyanensis .Old World CL is less commonly associated with sporotrichoid presentation but several cases have been reported from the Middle East .It is very rare in Europe and only a few cases have been reported in Italy.
33LeprosyIt is primarily a granulomatous disease of the peripheral nerves and mucosa of the upper respiratory tract.Skin lesions are the primary external sign.Left untreated, leprosy can be progressive, causing permanent damage to the skin, nerves, limbs and eyes.
34Lupus volgaris (a sort of cutaneus TB) Persistent and progressive form of cutaneous TB.Small sharply defined reddish-brown lesions with a gelatinous consistency (called apple-jelly nodules).Lesions persist for years, leading to disfigurement and sometimes skin cancer
38Two children with visceral leishmaniasis Two children with visceral leishmaniasis. The size of the spleen is marked on the abdomen. Normally the spleen does not protrude below the bottom rib.Photograph provided by COL Charles Oster
39Systemic infection of reticulo-entdothelial cells (mostly macrophages) throughout multiple internal organs and the blood
40Kala-azar , Visceral Leishmaniasis L. donovani complexL. donovani (Asia, East Africa)Strain archibaldiL. infantum (Medditeranian basin and Middle East, in children)L. chagasi ( South & Central America)L. tropica (viscerotropic)L. amazonensisWeeks to months (2-6 months) incubation period
42The most sever leishmaniasis form Mortality of untreated disease 75-95%Prolonged fever (usually dromedary but also continuous, reminant, interminnent)Splenomegaly, hepatomeglay,Weight loss (cachexia),Progressive anemia, pancytopenia,Hypergammaglobulinemia and hypoalbominemiaSkin darkness ( around mounth, forehead, temple)Lymphadenopathy may be presentElevated liver enzymes, Nausea, vomiting.Pancytopenia: normochrome & normocytic anemia, trombocytopenia, but lymphocytosispoor feeding,
43Visceral Leishmaniasis Visceral leishmaniasis should be considered in every case with chronic fever returning from an endemic area.Malaria, tropical splenomegaly, schistosomiasis, cirrhosis, portal hypertension, trypanosomiasis, milliary tuberculosis, brucellosis, typhoid fever, bacterial endocarditis, histoplasmosis, malnutrition, lymphoma, and leukemia (Singh, 2006).Apart from fly biting, other routes including; Placental, blood transfusion, mechanical, sexual routes.From the Desert Storm experience, would also consider visceral leishmaniasis in patients with low grade elevated temperature, chronically elevated liver function tests and mild anemiaSymptoms usually occur months after sandfly bitingBecause symptoms are non-specific and often start after redeployment there is usually a delay in diagnosis.
44Post kala-azar dermal leishmaniasis (PKDL) Sequel of VL which may manifest years after successful treatment and resolution of Kala-azar.Dermal lesions may contain parasites in great numbers.Post Kala-azar Dermal Leishmaniasis (PKDL) has been caused by L. donovani in East Africa and IndiaPigmentation, red or skin-colored macule, non-ulcerative nodules
45Viscerotropic leishmaniasis L. tropicaOligoparasitic leishmaniasisFever, fatigue, digestive tract problemsFirst in desert storm operation in Iraq among American soldiersIn Iran: One case from AIDS patient (Tehran), other case (Shiraz)
46Epidemiology of visceral leishmaniasis in Iran Mediterranean Kala-azar:- Causative agent is L. infantum- Reservior host: involving canine such as Dog, Jackal, fox, wolf and other wild carnivorouses.- The probable main vector in Iran is Phlebotomus major (Fars), other vectors are P.keshishiani (Fars), P. Perfiliewi (Dashte-Moghan),P. kandelakii (Meshkinshahr).- Age distribution: the disease mainly occurs in children from to 4 years of age.
51Espundia or mucocutaenous leishmaniasis (con.) May occur months to years after original skin lesion.Lesions can be very disfiguring and destroy all soft parts of the nose and the lips.Death can occurs through secondary bacterial infection.Occurs with Leishmania species from Central and South AmericaVery rarely associated with L. tropica and L. major which are found in the Middle EastHard to confirm diagnosis as few parasites are in the lesion
52L. (V.) panamensis (ulcer de bejuco) Three main agents:L. (V.) braziliensis (espundia=MCL)MCL Main causative agentRodents, occasionally dog and hoarseFirst self-healing cutaneousAfter 6 months to years espundia (80% in nasopharynx and nose)L. (V.) panamensis (ulcer de bejuco)MCL second rank agentSloth, rodent, monkeyAlong lymphatic vein involves the nasopharynxL. (V.) guyanensis (painbois=CL)Frequent relapseSloth, MyrmecophagidaeLike sporotrichosis (along lymphatic veins)
571. Clinical Diagnosis:Patient history ( endemic region or travel),Signs & symptomsSores that will not heal, have to be referred for evaluation.Individuals with fevers, weight loss, gastrointestinal complaints, anemia, hypergammaglobulinemia, abnormal liver tests should be referred for evaluation
58Laboratory Diagnosis of leishmaniasis : 1. Cutaneous LeishmaniasisTissue sample (scraping, aspirate or punch biopsy) for smear and cultureTake scrapings from the sore, put on slides, stain with Wright’s or Giemsa’s stains, and look for amastigotes.Culture (NNN & LIT, Evans, RPMI 1640),Laboratory animals inoculation (Souri andBalb/c mouse) only for L. major (no growth in L. tropica)On occasion, a deep scraping of a skin lesion can be sufficient when the tissue scraping is subjected to giemsa stain, Leishmania culture and/or PCR.
59Cutaneous Leishmaniasis (con.) Leishmania skin test (Montenegro test)0.1 ml (1,000,000 killed L. major promastigote), intradermal,5mm< induration after 48-72h, DTHIsoenzyme profiles - ZymodemesNo serological approaches usually but monoclonal antibodies can be used.DNA hybridisation - PCR
602. Visceral Leishmaniasis Finding Leishmania on biopsy of bone marrow (iliac, sternum, tibia (54-86% sensitivity)), liver (60%), enlarged lymph node (64%), or spleen (98%).Culture (NNN, Evans, LIT)Laboratory animals IP inoculation (Golden hamester)No LST for VL and PKDL diagnosis (Yes for VL and CL epidemiology and MCL and Lupoid diagnosis)Methods available in the US for antibody detection in the serum- IFA test- rk39 dipstick (Kalazar DetectTM)
61Visceral Leishmaniasis (con.) Serologic tests:Antibody detection: DAT (sen %, spe 72-95%) IFA (sen 55-70, spe 70-89) ELISA,( sen % spe 84-95) Dipstick test (rk39, recombinant antigen 39kd, sen % spe %)DAT is easy, inexpensive, and with high specificity and sensitivity (most usage in Iran)Antigen detection: KAtex (5-20 kd glycoprotein, membranous antigen, easy, field applicable, sen %, spe 100%, positive only in acute disease, useful for HIV/VL )Formel gel, (Based on hyperimmunoglobulinemia)Multiple myeloma, SchistosomiasisIsoenzyme profiles - ZymodemesMonoclonal antibodiesDNA hybridisation – PCR (Schizodem)
643. Mucocutaneous Leishmaniasis diagnosis Early diagnosis and treatment is critical to avoid disfigurementBiopsies should be done but require special training to avoid further disfigurement.Biopsies would be evaluated by the same methods and special laboratories as for cutaneous lesionBecause few parasites are present, PCR may be particularly useful
65Cutaneous and mucocutaneous treatment Antimony components : Meglumine antimoniate (Glucantime) and Sodium stibogluconate (Pentostam) are drugs of choice.20 mg/kg/d IV or IM for 20dPentamidine, Paromomycin are alternative drugs for CLAmphotricine B for antimony resistant MCLFluconazole may decrease healing timeSince L tropica is of more concern in the SWA theatre (because of potential visceralizing infection, rare mucocutaneous involvement, and chronic (recidivans) skin infection) , would not advocate use of azoles routinely as there is not data to support their use in L.tropica and speciation can not be reliably made using clinical appearance.Mucocutaneous infection is treated with a longer treatment course (28 days)
66Visceral leishmaniasis treatment Pentostam or Glucantime 20 mg /kg/d IV or IM for 28dAmphotricin B: mg/kg IV daily 15-20dLiposomal Amphotricin B (Ambisome): 3 mg/kg/d IV on days 1-5, day 14 and day 21Low toxicity and high stability, better deliveryAlternative: Pentamidine (4mg/kg three times weekly, between 5-25 weeks ), ParmomycineIt is not known what species of visceral leishmaniasis is present in Iraq – WHO reports that children have L. infantum. During Desert Storm some of American soldiers were found to have visceral infection with L. tropica. Published studies of liposomal amphotericin for visceral leishmaniasis have not included patients with L. tropica so it is not known for sure that it would be effective but it is expected likely.
67Visceral leishmaniasis treatment (con.) Miltefosine (Impavido) (2.5 mg/kg /d p.o. for 28 d)It was developed for cancer therapy at firstThe only oral drugsafer and more tolerable drug (less toxicity for bone marrow and haematopoietic progenitor cells)teratogenic
69Leishmaniasis control Vector controlinsecticidesinsecticide impregnated bed nets (IIB)Case finding treatmentAniaml reservoir controlTreatment or killing of seropositive dogsRodent killingDecrease of susceptibility: Childhood age, malnutrition and Immunosuppression are susceptibility factors for VL.eliminating of childhood malnutritiontry to produce an efficient vaccine
79روش نمونه برداری از ضایعات لیشمانیوز پوستی کناره های ملتهب و متورم ضایعات پوستی(لبه خارجی زخم) بیشترین میزان آمستیگوت را دارد.هر چه بافت بیشتر شانس یافتن آمستیگوت بیشترتمیز کردن محل زخم با پنبه و الکل 70%، با توجه به عفونت باکتریایی و قارچی بر روی ضایعه سالکخشک شدن الکل قبل از نمونه برداریمحل نمونه برداری توسط انگشت شصت و سبابه محکم گرفته شود.توسط تیغه اسکالپل نوک باریک و یا لانست استریل شکافی به عمق یک میلی متر در ناحیه ای که توسط دو انگشت گرفته شده ایجاد می شود.از عمق محل شکافته شده خراشهایی به سمت سطح و مرکز ضایعه جهت برداشت نمونه داده می شود.
80ادامه روش نمونه برداری از ضایعات لیشمانیوز پوستی نوک تیغه اسکالپل را خارج و از مواد برداشت شده 3 اسمیر گرفته می شود و با قلم الماس شماره نمونه یا اسم بیمار بر روی لام شیشه ای ثبت شود.در صورت نیاز به کشت، در کنار شعله نمونه ( بر روی تیغه اسکالپل) به درون محیط کشت دایفازیک منتقل می شود.
81رنگ آمیزی گیمسا محلول تجارتی غلیظ (و متفاوت) پس از رقیق سازی بتواند گلبول سفید را به خوبی رنگ کند.اسلاید حاوی نمونه بدون شعله ودر دمای اتاق خشک شوند.متانول Methanol 70%متانول خشک شود (اصطلاحا بپرد)بسته به دستور تولید کننده مثلا 1 به 30 یا 1 به 50 رنگ رقیق شود.آبی که جهت رقیق کردن استفاده می شود جهت pH تنظیم شده باشد.بسته به رقت و نوع آن مدت رنگ آمیزی دقیقه است که به طور تجربی بدست می آید.مشاهده با عدسی شیئی 10 و سپس 40 و سپس 100 (با روغن ایمرسیون) ومستقیما بدون لاملحداقل جستجوی 30 شان و یافتن ماکروفاژها در هر کدام از 3 لامنبود ماکروفاژ و فراوانی گلبول قرمز نشانه نمونه نامناسب inadequate)) و ضرورت نمونه گیری مجدد
82ایزولاسیون کشت در محیط NNN Novy, Macneal, Nicolleآگار 14 گرمNaCl 6 گرمآب مقطر cc 900حرارت (جوشاندن) تا شفاف شدن ( ولی احتیاط جهت سر ریز نشدن)اتو کلاو و سپس سرد شدن تا حرارت درجهاضافه کردن گلوکز 30گرم در صد به میزان 5 درصداضافه کردن خون خرگوش دفیبرینه درصد حجم محلولبه صورت گرم، تقسیم در لوله های استریل درپیچ دار (3 میلی لیتر)، قرار دادن به شکل slantانتقال به یخچال پس از بستن آگاردر هنگام استفاده، اضافه کردن 0.5 تا 1 سی سی PBS یا RPMI به عنوان فاز مایع
83ادامه کشت نمونه بیوپسی پوستی، آسپیراسیون مغز استخوان و خون 2 میلی متر در عمق پایین ترین سطح شیب داراینکوباسیون در درجه سانتیگرادانگل در فاز مایع رشد کرده و یافت خواهد شد.استریل کار کردن: باکتری و قارچ مانع رشد انگل هستند.بررسی کشت جهت جستجوی انگل: هفته ای یکبار و تا یکماه ( عدم رشد معادل منفی بودن است).اگر انگل دیر رشد باشد زمان بیشتری را نیاز دارد.
84Leishmaniasis Control WHO interestAfrican trypanosomiasis>Dengo>Leishmaniasis>Malaria>Schistosomiasis>Lymphatic filiriasis> ChagasClose contact of humans and their domestic animals can provide optimal conditions for sand flies and Leishmania transmission (stables provide good breeding ground for larvae)In urban environments infection is mostly human to humanIn rural areas Leishmaniasis can be a zoonosisInfection in dogs is quite frequent in the Mediterranean
85Ecology of new world leishmaniasis In the new world most people get infected while working or hunting in the forestHere wild animals including rodents, monkeys and sloths provide a reservoir for the parasiteA transmission pattern within a population of wild animals that result in occasional infection of humans is called sylvatic
86In sand fly, amastigotes are surrounded by a peritrophic membrane (PM), a chitin lattice embedded in protein carbohydrate matrix secreted by the epithelium of midgut.Round amastigotes transform to short ellipsoid procyclic promastigotes (6-8mm length). Procyclic promastigotes multiplicate within PM but gradually transform to nectomonad form when divide (in a more elongated form with μm body length).Nectomonades migrate from posterior midgut to anterior part and then into thoracic midgut and cardiac valve. After PM disintegration, some nectomonades attach to midgut epithelium particularly in the thoracic midgut in the vicinity of cardiac valve, inserting their flagella between the microvilli and then transform to haptomonad (5-8µm broad, shorter cells).From day five post feeding, metacyclic infective promastigotes can be observed in lumen (in a detached position). metacyclic promastigote are injected through the food channel in the sand fly proboscis.
87Cutaneous Leishmaniasis in Birjand It is estimated that in recent years an endemic zone of CL has been emerged in Birjand area.In our study, among 80 Giemsa stained smears of CL patients in Birjand which identified by PCR methods, 8 (10%) had Leishmania major and 72 others infected by Leishmania tropica. So both Zoonotic and Anthroponotic cutaneous leishmaniais are endemic in this region.
88Cutaneous Leishmaniasis is usually self-limiting A chronic but self-limiting dry ulceration at the site of the biteParasites are not found outside the lesionNearly absolute resistance to reinfectionInoculation to vaccinate has long been practiced in the middle east
89Sporotrichoid form:dissemination of amastigotes via the lymphatics to the subcutaneous tissues.Regional lymphadenopathy with feverDifferent cases from Panama and Brazil. The main causative agents were L (V) panamensis and L (V) guyanensis (Herwaldt, 1999; Melby et al.1992). Old World cutaneous leishmaniasis is less commonly associated with sporotrichoid presentation but several cases have been reported from the Middle East (Kibbi et al. 1987; Ayattolahi, 2006). It is very rare in Europe and only a few cases have been reported in Italy.
90Cutaneous leishmaniasis differentials Fungal –Paracoccidioidomycosis, chromoblastomycosis, sporotrichosis, blastomycosisBacterial – Staphylococcal and streptococcal infections, pinta, yaws, syphilis, tuberculosis, leprosy, cutaneous diphtheria, tularemia, tropical pyoderma, and other mycobacteriosesViral -OrfOrf is an exanthemous disease caused by a parapox virus and occurring primarily in sheep and goats. It is also known as contagious pustular dermatitis, infectious labial dermatitis, ecthyma contagiosum, thistle disease and scabby mouth. Orf virus is zoonotic - it can also infect humans.Inflammatory - Sarcoidosis, pyogenic granuloma, lupusNeoplastic - Cutaneous T-cell lymphoma, basal cell carcinoma, squamous cell carcinoma, metastases, Psoriasis, Keloids
91peritrophic membrane (PM), a chitin lattice embedded in protein carbohydrate matrix secreted by the epithelium of midgut.Round amastigotes transform to short ellipsoid multiplicating procyclic promastigotes (6-8mm length).Procyclic promastigotes gradually transform to nectomonad form when divide (in a more elongated form with μm body length).Nectomonades migrate from posterior midgut to anterior part and then into thoracic midgut and cardiac valve.Nectomonades attach to midgut epithelium particularly in the thoracic midgut in the vicinity of cardiac valve, inserting their flagella between the microvilli and then transform to haptomonad (5-8µm broad, shorter cells).From day five post feeding, metacyclic infective promastigotes can be observed in lumen (in a detached position). metacyclic promastigote are injected through the food channel in the sand fly proboscis.
93Animal leishmania that occatinally transmitted to human L. inerity (guinapig): linear kinetoplast, large cytoplasmic vacule, metastatic propertyL. adlery, L. agame, L. gimnodactily (خزندگانL. turanica, L. gerbili, L, arabica (rodents)L. daini ( the biggest Leishmania amastigote), L. hertigi ( خارپشت)
95Iran: Bam, Shiraz, Kerman, Tehran, Mashhad, Sabzevar, Neishaboor L. tropica in world:P. sergentiP. cocasicusIran: Bam, Shiraz, Kerman, Tehran, Mashhad, Sabzevar, NeishaboorIn all seasons
96In last summer month and first fall L. majorIn world: P. papatasi, P. lonipes, P. cocacicus, P. AnsariIn Iran: Rhombomys opimus ( central;Isfahan, Fars, northeast: khorasan), Meriones libycus (Yazd), M.hurrianae (southest: sistan & Bloochestan), Tatera indica, Nosekia indica (west: khozestan)In last summer month and first fall
97LST is positive in: cured VL, MCL, last ACL phase (recidivans) L. aethiopicaP. PediferHyraxDue to immune deficecy in second signall (B71(CD80) and B72(CD86) in CMIAnergyNo response to treatmentLST is negative in:DCL, VL, PKDL, early phase of urban CLLST is positive in: cured VL, MCL, last ACL phase (recidivans)
99Aconitate hydratase diffrentiate leishmania subgenus from viannia
100New World cutaneous leishmaniasis L. mexicana (Chicleros Ulcer)External earRodent, humanCL and DCLL. pifanoi (DCL)DCL like L. aethiopicaL. amazonensismain cause of DCLNot kealing DCL in AIDSAll four leishmaniasis formsRodent, Oposum, FoxL. (V.) peruviana (Uta)Like L. tropica self-healing lesionProbably originated from L. tropica but differe in zymodem.Reservoir :Dog, and probably a redontL. granhamiL. venezuelensis
101L. chagasi (similar zymodem and schizodem pattern with L. infantum) American kala-azar:L. chagasi (similar zymodem and schizodem pattern with L. infantum)Dogs and foxL. longipalpisIndian kala-azaranthroponoticP. argantipes5-9 yearsPKDL in 20% of cases 6 months after healingLoaded amastigotesA good source for sandflyButterfly distribution on face (like lupus)No systematic manifestation such as fever and splenomegaly
102Medditereanian kala-azar Middle east and Meditteranian basin1-4 years childrenCanideaP. major, P. longicuspis, P, chinensis, P. perfiliewi, P. kandelakii, P. ariasi, P. perniciosus
103G6PD enzyme can differentiate L. guyanensis from L. panamensis L. laiensoiAgotiL. colombiensissloth
104L. (V.) panamensis (Ulcer de bejuco) Three main agents:L. (V.) braziliensis (Espundia=MCL)MCL Main causative agentRodents, occasionally dog and hoarseFirst self-healing cutaneousAfter 6 months to years Espundia (80% in nasopharynx and nose)Fastidious growth in cultureReflecting bodiesL. (V.) panamensis (Ulcer de bejuco)MCL second rank agentSloth, rodent, monkeyAlong lymphatic vein involves the nasopharynxSandfly: Luteromia, psycodopigusEasily growthable in culture mediaL. (V.) guyanensis (Painbois=CL)Frequent relapseMetastaticSloth, مورچه خوارLike sporotrichoid (along lymphatic veins)
105GP63 Major surface protein, metaloprotease (Zn) Hb degradation and role in promastigote methabolismResistance against lysosome function in macrophage phagolyzozomeRole in attachment of parasite to macrophage receptors CR1 (CD35) and CR3 (CD11blCD18)Degradation of collagen and fibronectin
106LPG 25% of promastigote weight Role in attachment of parasite to macrophage receptorsProteinase C inhibitionPhagosome-lysosome attachment inhibitionProtection against tripsin enzyme in sandfly midgutRole in glycocalex production and protection against lysosome
107Glycosyl phospatidyl inositol Glycocalyx conformationResistance against lysosome in phagolysosome
108Biohasic media Monophasic media NNN LIT Evans HOMEM RPMI1640 Graces Schneider drosophila
109Leishmania and Trypanosoma From the seven genera in the Trypanosomatidae family, only 2 genera, Leishmania and Trypanosoma, are important parasites of humans.Not all parasites in the family possess all the four morphological forms:Leishmania spp. - possesses only amastigote & promastigote formsTrypanosoma brucei - has only epimastigote & trypomastigoteTrypanosoma cruzi - has all four forms
112Cutaneous and mucocutaneous treatment Antimony components : Meglumine antimoniate (Glucantime) and Sodium stibogluconate (Pentostam) are drugs of choice.20 mg per kg, daily IV or IM for 20dPentamidine, Paromomycin are alternative drugs for CLAmphotricine B for antimony resistant MCLFluconazole may decrease healing time in L. major infectionSince L tropica is of more concern in the SWA theatre (because of potential visceralizing infection, rare mucocutaneous involvement, and chronic (recidivans) skin infection) , would not advocate use of azoles routinely as there is not data to support their use in L.tropica and speciation can not be reliably made using clinical appearance.Mucocutaneous infection is treated with a longer treatment course (28 days)
113Leishmaniasis Control WHO interestAfrican trypanosomiasis>Dengo>Leishmaniasis>Malaria>Schistosomiasis>Lymphatic filiriasis> ChagasClose contact of humans and their domestic animals can provide optimal conditions for sand flies and Leishmania transmission (stables provide good breeding ground for larvae)In urban environments infection is mostly human to humanIn rural areas Leishmaniasis can be a zoonosisInfection in dogs is quite frequent in the Mediterranean
114Ecology of new world leishmaniasis In the new world most people get infected while working or hunting in the forestHere wild animals including rodents, monkeys and sloths provide a reservoir for the parasiteA transmission pattern within a population of wild animals that result in occasional infection of humans is called sylvatic
115reaction is seen in people with previous contact to the antigen who have developed cellular immunity. Conversion occurs after several weeks in CL, and in VL usually only after treatment and cure (Peters and Killick-Kendrick, 1987). Present and past infections can not bedifferentiated.The Montenegro skin test is occasionallyused in diagnosis of cutaneous disease (eg, in epidemiological surveys), because of its simple use and high sensitivity and specifi city;118 however, it fails to distinguish between past and present infections.Pentavalent antimonial drugsPentavalent antimony has been drug of choice for all forms of leishmaniasis such as visceral leishmaniasis. Two of the most important drugs of this class are Sodium stibogluconate and Meglumine antimoniate. Toxicity and parenteral administration make them not ideal. Some side effects with the spectrum from arthralgias and ache to chemical pancreatitis have been observed (Roscoe, 2005). In India and some other regions, resistance to these drugs is a rising problem (Bhattacharyya et al. 2002). Administration dosage of them is 20mg/kg/day for 28 days in case of VL and for 20 days in case of CL (Herwaldt, 1999