1. KALA AZAR
Dr.Alaa jumaa

2. kala azar, black fever, sandfly disease, Dum-Dum fever and espundia.
SYNONYMS
kala azar, black fever, sandfly disease, Dum-Dum fever and espundia.

3. Leishmania throughout the ages…
one of the first and most important clinical descriptions was made in 1756 by Alexander Russell following an examination of a Turkish patient. The disease, then commonly known as "Aleppo boil"
In 1901, Leishman identified certain organisms in smears taken from the spleen of a patient who had died from "dum-dum fever"
in 1903 Captain Donovan described them as being new.

4. Pre-Incan pottery from Ecuador and Peru also show individuals with facial deformities and skin lesions

5. Introduction
Leishmaniasis is a parasitic disease transmitted by the bite of sand flies.
Found in parts of at least 88 countries including the Middle East
Three main forms of leishmaniasis
Cutaneous: involving the skin at the site of a sandfly bite
Visceral: involving liver, spleen, and bone marrow
Mucocutaneous: involving mucous membranes of the mouth and nose after spread from a nearby cutaneous lesion (very rare)
Different species of Leishmania cause different forms of disease

6. Leishmaniasis Leishmania donovani (complex) (VL)
Leishmania tropica (CL)
Leishmania major (CL)
Leishmania aethiopica (CL)
Leishmania mexicana (Complex) (CL)
Leishmania brazilliensis (complex) (MCL)
Leishmania peruriana

7. Introduction
In the Middle East L. major and L. tropica are the most common species
L. major causes skin infection
L. tropica causes skin and visceral infection and rarely causes mucocutaneous infection

8. Leishmaniasis in the Middle East
90% of cutaneous leishmaniasis occurs in Afghanistan, Iran, Saudi Arabia, Syria, Brazil and Peru
8,779 cases were reported in Iraq in 1992
Sore is commonly called the Baghdad boil
At least 20 cases of cutaneous leishmaniasis were reported in Americans from Desert Storm
90% of all visceral leishmaniasis occurs in Bangladesh, Brazil, India, and the Sudan
2893 cases were reported in Iraq in 2001
12 visceral leish cases were reported in Americans in Desert Storm
90% of mucocutaneous leishmaniasis occurs in Bolivia, Brazil and Peru
Rarely associated with L tropica which is found in Middle East
Data on leishmaniasis is based on voluntary reporting by countries so true incidence may be higher in countries that are not likely to report.
Numbers of cases in Iraq come from recent Promed messages (authors Desjeux and Deresinki)

9. The Parasite Phylum Sarcomastigophora Order Kinetoplastida Family
Genus
Sarcomastigophora
Kinetoplastida
Trypanosomatidae
Leishmania

10. Morphology Promasitogte Amastigote Insect Motile Midgut
Digenetic Life Cycle
Promasitogte
Insect
Motile
Midgut
Amastigote
Mammalian stage
Non-motile
Intracellular

11. Promastigote

12. Amastigote

13. A macrophage filled with Leishmania amastigotes.

14. The vector
The insect vector of leishmaniasis, the phlebotomine sandfly, is found throughout the world's inter-tropical and temperate regions.
The female sandfly lays its eggs in the burrows of certain rodents, in the bark of old trees, in ruined buildings, in cracks in house walls, in animal shelters and in household rubbish, as it is in such environments that the larvae will find the organic matter, heat and humidity which are necessary for their development. In its search for blood (usually in the evening and at night), the female sandfly covers a radius of a few to several hundred metres around its habitat.

17. Cutaneous forms
Cutaneous forms of the disease normally produce skin ulcers on the exposed parts of the body such as the face, arms and legs. The disease can produce a large number of lesions - sometimes up to causing serious disability and invariably leaving the patient permanently scarred, a stigma which can cause serious social prejudice.

18. Photograph provided by COL Naomi Aronson

19. Photograph provided by COL Naomi Aronson

20. Mucocutaneous forms
In mucocutaneous forms of leishmaniasis, lesions can lead to partial or total destruction of the mucous membranes of the nose, mouth and throat cavities and surrounding tissues. These disabling and degrading forms of leishmaniasis can result in victims being humiliated and cast out from society.

21. Photograph provided courtesy of COL Donald Skillman

22. Visceral Leishmaniasis
Most severe form of the disease, may be fatal if left untreated
Usually associated with fever, weight loss, and an enlarged spleen and liver
Anemia (low RBC), leukopenia (low WBC), and thrombocytopenia (low platelets) are common
Lymphadenopathy may be present
Visceral disease from the Middle East is usually milder with less specific findings than visceral leishmaniasis from other areas of the world
Based on our experience with Desert Storm, well nourished American soldiers generally have a less symptomatic, relatively oligoparasitic infection that was not life threatening but posed some diagnostic challenges

24. Diagnosis For Visceral Leishmaniasis:
enzyme liked immunosorbent assay (ELISA)
direct agglutination test (DAT)
indirect fluorescent antibody test (IFAT)

25. Diagnosis
n patients with VL, smears or cultures of material from splenic, bone marrow, or lymph node aspirations are usually diagnostic.
In experienced hands, splenic aspiration has a higher diagnostic sensitivity.

26. LABORATORY FINDINGS
Laboratory findings associated with classic kala-azar include anemia
(hemoglobin 5–8 g/dL),
thrombocytopenia,
leukopenia (2,000–3,000 cells/μL),
elevated hepatic transaminase levels,
and hyperglobulinemia (>5 g/dL) that is mostly immunoglobulin G (IgG).

27. Treatment
The pentavalent antimony compounds (sodium stibogluconate [Pentostam], and meglumine antimoniate have been the mainstay of antileishmanial chemotherapy for >40 yr.
Cure rates with this regimen of 80–100% for VL
lower initial cure rates have been noted recently in regions where clinical resistance to antimony therapy is common.
Relapses are common in patients who do not have an effective antileishmanial cellular immune response.
Adverse effects of antimony therapy

28. Treatment
Liposomal amphotericin B (3 mg/kg on days 1–5, and again on day 10) has been shown to be highly effective, with a 90–100% cure rate for VL.
Liposomal amphotericin B is approved by the Food and Drug Administration for treatment of VL and should be considered for 1st line therapy in the United States.
Parenteral treatment of VL with the aminoglycoside paromomycin (aminosidine) has efficacy (95%) similar to that of amphotericin B in India.
Recombinant human interferon-γ has been successfully used as an adjunct to antimony therapy in the treatment of refractory cases of ML and VL

29. Treatment
March st oral drug for visceral leishmaniasis registered (milefosine)
currently used in India
safe and effective  up to 98% cure rate
mild side-effects  vomiting and diarrhea
does not require refrigeration
Other drugs- sitamaquine and aminosidine