CANINE

LEISHMANIOSIS

CANINE
LEISHMANIOSIS
 CANINE
LEISHMANIOSIS

PROF. GUADALUPE MIRÓ

Professor Guadalupe Miró qualified from the
Madrid Veterinary School where she also completed
her PhD. She is Full Professor in Parasitology and
Parasitic Diseases at the Animal Health Department,
Universidad Complutense of Madrid (UCM), a
Diplomate of the European Veterinary Parasitology
College (EVPC) and Director of the UCM Pet Parasite
Laboratory. Professor Miró is also currently in
charge of the Infectious Diseases Consultancy at
the Veterinary Teaching Hospital of the Madrid
Veterinary School with a special focus on infectious
diseases of small animals. Her areas of research
specialisation are vector borne diseases of pets and
wildlife, canine & other animal leishmaniosis and
shelter medicine involving the epidemiology and
control of zoonotic diseases. She is a member of the
World Association for the Advancement of Veterinary
Parasitology (WAAVP), the International Society for
Companion Animal Infectious Diseases (ISCAID), the
Spanish Society of Parasitology (SOCEPA). She is also
founding member of ESCCAP (Spain representative)
and LeishVet group (President) and member of the
main Spanish Associations of Veterinary Practitioners’
(AMVAC and AVEPA). Her scientific output consists of
numerous scientific articles in peer reviewed journals
and she is author of several books in the field.
 CANINE
LEISHMANIOSIS

INDEX

WHERE IS THE DISEASE MOST LIKELY TO BE FOUND?...................................................................................................4

HOW DOES A DOG BECOME INFECTED?.......................................................................................................................................................6

WHAT BEHAVIORS PUT A DOG AT RISK FOR THE DISEASE?............................................................................13

CAN A DOG BE INFECTED AND NOT SHOW SIGNS?........................................................................................................14

WHAT CLINICAL SIGNS DOES A SICK DOG SHOW AND WHY?..................................................................16

WHAT DIAGNOSTIC TESTS SHOULD BE RUN IN A DOG

THAT IS SUSPECTED TO HAVE THE INFECTION/DISEASE?..................................................................................19

WHAT GENERAL TREATMENT STRATEGY IS RECOMMENDED

FOR SICK DOGS?........................................................................................................................................................................................................................................22

ARE OTHER PETS OR PEOPLE IN THE HOUSE AT RISK?..............................................................................................25

WHAT ARE SOME RECOMMENDATIONS AROUND

PREVENTION STRATEGIES?................................................................................................................................................................................................26

WHAT DOES THE FUTURE LOOK LIKE?...........................................................................................................................................................29

FURTHER READING...............................................................................................................................................................................................................................31

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 CANINE
LEISHMANIOSIS

WHERE IS THE DISEASE

MOST LIKELY TO BE FOUND?
Leishmaniosis refers to a group of diseases with a worldwide distribution caused by protozoa of the genus Leishmania
(family Trypanosomatidae). Leishmania is transmitted by dipteran flies belonging to the genus Phlebotomus in the Old
World and Lutzomyia in the New World (Family Psychodidae).

Geography
Canine leishmaniosis was first described in Tunisia in
1908 and currently is known to be prevalent in 50 of the
92 countries where human leishmaniosis is present.
Geographic regions considered endemic are Southern
Europe, Africa, the Middle East, the Far East and
Central and South America. Currently there are
estimated to be 15 million infected dogs in the world
and more than 2.5 million of them suffer from clinical
signs of this disease. A dog showing classic signs of canine leishmaniosis.

Local environment
Leishmania infantum (syn. L. chagasi) is the most
prevalent protozoa species causing disease in dogs and
is endemic at a high level in the Mediterranean Basin
in Europe and Brazil in South America. Although
dogs are the main reservoir of the domestic cycle of
infection, Leishmania spp affect various animal species
(including people). There is also a wilderness cycle of
infection maintained mainly by wild canids (fox, wolf,
jackal) and a long list of species (felines, ruminants,
equines, rodents, lagomorphs, marsupials, primates,
etc.) in which the infection has been described. Wild canids as reservoirs of Leishmania spp.

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WHERE IS THE DISEASE MOST LIKELY TO BE FOUND? LEISHMANIOSIS

Favorable climate conditions

Canine leishmaniosis is endemic in areas where
climatic conditions are optimal for development of the
phlebotomine flies (“sand flies”) that are Leishmania
vectors. Therefore, these bioclimatic factors are
critical for development of the sand fly vector and vary
according to different geographic areas.

The sand fly’s maximum daily activity begins

after sunset and continues during the early
hours of the night, provided the temperature does
not drop below 17-18ºC or exceed 40ºC; there is no Under 10 ºC the sand fly’s development is greatly
rain or wind, and altitudes are 1000 m and below. delayed, and freezing temperatures are lethal.

Evidence of infection / disease spread

Leishmaniosis in dogs is spreading into new areas
because of the impacts of climate change providing
new microclimates where the sand fly can survive and
also from movement of animals and people.

Within Europe, many imported cases of canine

leishmaniosis have been diagnosed in countries
considered to be non-endemic and these dogs are
suspected to have been transported from endemic areas.

Similarly, in South America, many countries have

reported a significant number of cases to date,
although the highest prevalence is still in Brazil.

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LEISHMANIOSIS

HOW DOES A DOG

BECOME INFECTED?
An introduction to the causative agent and lifecycle
The genus Leishmania is divided into two subgenera: cycle that takes place in two types of hosts:
Leishmania (replication in the sand fly mid-gut) and
Viannia (replication in the sand fly distal intestine). A vertebrate host (dog or other species)
An invertebrate host (the phlebotomine
The protozoa species that cause disease in dogs, sand fly vector)
L. infantum, is a digenic protozoa with a biological

Information on Leishmania species and their vectors that may cause infection and disease in dogs
Leishmania spp Main geographic distribution Hosts other than dogs Sand fly species
An introduction to the
Mediterranean basin,causative
Middle east, agent
Humans, and lifecycle
other primates, canids, cats, Phlebotomus perniciosus,
L. infantum Asia, North Africa, South felids, rodents, lagomorphs, P. ariasi, P. langeroni, P. neglectus,
syn. L.The
chagasi
genus Leishmania isand
divided
Centralinto two subgenera: Leishmania
America herbivorous,(replication
marsupials,inbats
the fly mid-gut)P. and Viannia
perfiliewi, (replication
P. tobi and othersin the
fly distal intestine).
North Africa, Middle East,
L. tropica Humans P. sergenti
Southeast Asia
The protozoa species that cause disease in dogs, L. infantum, is a digenic protozoa with a biological cycle that takes
P. papatasi, P. duboscqi,
L. place
major in two types of hosts:
North Africa, Middle East Humans, rodents
P. alexandri, P. ansarii
A vertebrate (dogAsia,
L. donovani or other
Africaspecies)
Cyprus (dog) Humans P. argentipes, P. martini
L. braziliensis Brazil
An invertebrate (the phlebotomine fly vector) Humans Lutzomyia intermedia
L. mexicana Central America, Texas Humans, rodents Lu. olmeca
The protozoa have a distinct form in each host type.
L. amazonensis Brazil Humans, rodents Lutzomyia spp.
L. peruviana Peru Humans Lu. peruensis
L. pifanoi Venezuela Humans Lu. spp
L. colombiensis Colombia, Panama, Venezuela Humans, insectivores Lu. spp
L. panamensis Panama Humans Lu. panamensis

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HOW DOES A DOG BECOME INFECTED? LEISHMANIOSIS

The protozoa have a distinct form in each host type.

Nucleus

Definitive host (dog) Vector (sand fly)

Kinetoplast

Leishmania spp.
parasitic stages

Amastigote Promastigote
The form found in the vertebrate is called the The protozoa form found in the invertebrate
“amastigote”. This form is immobile, intracellular, is called the “promastigote” (from the Greek
round or oval, 2-6 μm, with a very short, almost “mastigos”- whip) - an elongated extracellular
imperceptible, flagellum. form with an anterior flagellum that is found in
These protozoa have a basophilic nucleus and the digestive tract of the vector.
a modified mitochondrion called a kinetoplast
and they parasitize cells of the mononuclear
phagocytic system (MPS). Genomic DNA
associated with parasite multiplication is found in
the nucleus while extra-chromosomic DNA is in
the kinetoplast.

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HOW DOES A DOG BECOME INFECTED? LEISHMANIOSIS

Vector (lifecycle)
Phlebotominae are the only arthropods capable of transmitting Leishmania spp infection. There are 600 known
species of phlebotomine sand flies, and at least 70 transmit Leishmania spp. These species belong to the genus
Phlebotomus in the Old World and Lutzomyia in the New World. They are mainly distributed in tropical areas
and palearctic regions. Phlebotomine sand flies have not been observed in Australia, New Zealand, the Pacific
Islands or Antarctica.

Phlebotomus spp

Luztomyia spp

They can also have a seasonal life cycle with peak activity in spring-summer in cooler areas. Sand flies
complete their lifecycle year-round in tropical regions, e.g. Brazil. They can survive the winter in diapause or hypobiosis
as a fourth larval stage. The known habitat can reach latitudes of 50º N and 40º S with some variation depending on
the great diversity of species and subspecies.

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HOW DOES A DOG BECOME INFECTED? LEISHMANIOSIS

Adult female sand flies feed on the blood of mammals

and birds and are opportunistic because they will bite
the most accessible host. However, they prefer dogs
compared to other potential hosts, including people.
Sand flies have a characteristic short, silent movement,
characterized by small zig-zag jumps (100-200 meters).
They can travel up to 2-3 km and this increases their
ability to spread Leishmania infection. The species are
endophilic with positive phototropism, meaning that
they will enter homes to feed and they have been found
as high as the 4th floor. Adult fed female sand fly (Phlebotomus sp.).

Sand fly life cycle

Sand flies belong to the Order Diptera. They are small (2-3 mm), yellowish in color, have erect lanceolate wings
that form an angle of 45º with the axis of the body, and have abundant hair covering the whole body. They are
holometabolic and undergo complex metamorphosis with four life stages. All life stages of the fly are terrestrial,
unlike mosquitoes which have aquatic larval stages.

Adult sand flies live an average of 30 days

1
1 and adult females feed 3-4 times, Adult
depending on weather conditions.

Females lay their eggs approximately

4-5 days after feeding, preferring sandy 2
Pupa

Egg
places (hence the common name “sand
2
flies”), burrows, stables, basements,
woods, sewers, wall cracks, garbage
dumps, etc.

Ideal insect “breeding” places are

characterized by moderate temperatures,
La
high relative humidity, dim light, and rva
va1
3 3 4 Lar
abundant animal or plant organic matter,
which will form the fundamental food
supply for larvae.

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HOW DOES A DOG BECOME INFECTED? LEISHMANIOSIS

Proportion of infected vectors

The proportion of infected phlebotomine vectors in
endemic areas is relatively low (0.5 - 3%). However,
significant increases in vector infection density have been
reported in specific situations (e.g. a human leishmaniosis
outbreak that occurred in Madrid in 2009) and there is an
extended period of vector activity, mainly due to higher
temperatures associated with climate change.

Xenodiagnostic studies show that sick dogs with

a more severe clinical picture are potentially more
infective to sand flies than dogs with a subclinical
Introduction of infected dogs into disease-free areas where
infection. The degree of infectivity is inversely phlebotomine sand fly vectors are present creates the potential
proportional to CD4+ levels in dogs. risk of developing a new focus of leishmaniosis.

Xenodiagnosis is a sensitive diagnostic technique that involves feeding uninfected sand flies on dogs
and then testing these sand flies for the parasite.

Reservoirs
The dog is a natural reservoir for L. infantum infection (syn. L. chagasi) and other mammals can act as accidental
or secondary reservoirs.

In addition, cases of clinical leishmaniosis

have been reported in Equidae (first in Brazil
This peri-domestic infection cycle includes and subsequently in the Mediterranean
primary reservoirs such as the dog, and Basin, Germany and Switzerland). A similar
secondary reservoirs, such as the horse, cat phenomenon occurred in the cat, although
and black rat. the first feline case was reported in Algeria
in 1912, and to date there are more than
a hundred well-described clinical cases.
Therefore, cats are also a reservoir that
can play an epidemiological role in the
Leishmania spp. cycle.

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HOW DOES A DOG BECOME INFECTED? LEISHMANIOSIS

Additionally, there is a wildlife cycle that includes

accidental reservoirs such as the wolf, Iberian
lynx, wildcat, marten, and badger. L. infantum
infection has been diagnosed in captive
A rural infection cycle also occurs and is wildlife, with disease confirmed in Bennett’s
represented by secondary reservoirs such as Wallaby (Macropus rufogriseus) and orangutan
lagomorphs and red fox. (Pongo pygmaeus pygmaeus) in Madrid.

Other routes of transmission

The most prevalent spread of Leishmania infection in endemic areas is through sand fly vector transmission. Other
arthropods have not been shown to be competent vectors of the infection.

However, diagnosis of other cases in these non-endemic areas demonstrates additional potential non-vector
transmission pathways of increasing concern.

In non-endemic areas without

a competent arthropod vector
including France, Germany,
and the United States, vertical
transmission is the most
widespread route.

Vertical transmission Sexual transmission

Blood transfusion Dog to dog

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HOW DOES A DOG BECOME INFECTED? LEISHMANIOSIS

Transmission mechanisms
Amastigote Promastigote
4 1

Schematic view of the Leishmania infantum life cycle.

The infected phlebotomine sand fly Inside phagocytes, the promastigotes lose their
has flagellated Leishmania promastigotes flagellum and multiply by binary fission until they
1 3 rupture the cell and release amastigotes. These
present in its proboscis, and when it bites a dog it
inoculates these with its saliva. amastigotes are in turn phagocytized by other cells
leading to massive intra-organ dissemination.

These promastigotes are then phagocytized by the

2 Amastigote-infected macrophages are taken up by
dog’s skin macrophages and/or monocytes.
another phlebotomine sand fly during a blood meal.
Inside the sand fly these convert into promastigotes
that actively multiply and undergo a series of
Non-vector transmission
pathways are known but do 4 modifications. They again become infectious within
not have an important role in the proboscis and are ready to complete the lifecycle
the epidemiology of canine by inoculation into a new vertebrate host. The cycle
leishmaniosis. within the vector is completed within 7-14 days in
conditions of optimal temperature and humidity.

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LEISHMANIOSIS

WHAT BEHAVIORS
PUT A DOG AT RISK FOR THE DISEASE?
Lifestyle There are several predisposing factors known to affect disease development
in infected dogs, including age, sex, breed, activity, genetic predisposition, im-
munocompromised status and habitat. The most important factor is the dura-
tion of exposure to the vector, that is, the hours that a dog spends outside.
Therefore, the dog’s lifestyle has an impact on the risk level for contracting
the infection. Guard dogs, shepherd breeds, and/or working dogs (e.g. police
dogs) have the highest risk because of their increased exposure to the vector.

The risk for dogs to become Leishmania infected is directly tied to Time of day for
infected sand flies present in their environment. The natural sand fly increased exposure
biology determines that the risk starts when minimum temperatures
rise to 17º C and are sustained above this level, for example in the early
summer in the Mediterranean area. The risk of transmission begins with
the fly feeding time at dusk and continues through the night until dawn.

Breed related risks All breeds are potentially susceptible to L. infantum infection. However, the
Ibizan Hound and crosses of this breed are more resistant to infection, asso-
ciated with an active cellular immune response. Conversely, Boxers have a
genetic predisposition to canine leishmaniosis that is linked to the Slc11c1
(Solute carrier family 11 member a1) gene, formerly called N-RAMPI, and
certain other Major Histocompatibility Complex Type II gene alleles.

Young dogs can show an increase in their serum anti-Leishmania antibody levels Age
and there could be a genetic predisposition or their immune system immaturity
leading to greater infection vulnerability in the early part of life. However, there
can also be a higher seroprevalence observed in older dogs that may result from
accumulated vector exposure time or from an increased susceptibly associated
with concomitant infectious or neoplastic diseases. Additionally, some cases
in older dogs could be caused by immunosuppressive therapy leading to
reactivation of a latent infection acquired earlier in life.

Contact with Canine leishmaniosis is a vector-borne disease and therefore

other animals healthy dogs can cohabit with infected dogs without, in principle,
any increase in risk. Direct transmission of Leishmania infection
between dogs, in the absence of sand flies, has been demonstrated,
but it is considered an unlikely scenario. The presence of a dog that
acquired the infection locally is an indication of the presence of the
vector and underlines the importance of vector protection for all dogs
in the household and others living in the same area.

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LEISHMANIOSIS

CAN A DOG BE INFECTED AND

NOT SHOW SIGNS?
Infection vs disease
There are two types of canine patients found in endemic areas:

Anti L. infantum antibodies can be detected in both types of dogs at different levels, although levels
are usually higher in the sick dogs.
The parasite can be observed in both types of dogs in hematopoietic organs by cytology and/or
molecular diagnosis.

It can be difficult to differentiate these two types of dogs, except through absence of clinical signs in
subclinically infected dogs and potential laboratory abnormalities in sick dogs.

1st type 2nd type

The clinically healthy infected dog that, The sick dog that develops a powerful,
thanks to developing an active cell-based immune but non-protective, humoral response that allows
response type Th1, does not show clinical signs or the parasite to evade the immune response
laboratory abnormalities. and become distributed throughout the body.
The result in a sick dog is production of parasitic
granulomas and immune complex deposition in
different organs. These are the changes that lead
to the wide variety of clinical signs and laboratory
abnormalities described in canine leishmaniosis.

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CAN A DOG BE INFECTED AND NOT SHOW SIGNS? LEISHMANIOSIS

Risk of subclinical disease (frequency in the population)

In endemic areas, the proportion of clinically healthy infected dogs can exceed 60%
of the total population, while the percentage of sick dogs is usually between 5 and 10%.
This high proportion of infected but apparently healthy dogs forms a large reservoir
for the parasite in the population.

Risk to the population from sub-clinically diseased dogs

Subclinical dogs do not develop clinical signs or laboratory abnormalities, but they infect
phlebotomine sand flies and thus perpetuate the infection. Therefore, these dogs transmit
the infection despite a lack of clinical signs and an apparently low parasite load. The risk of
parasite transmission from sick dogs is greater than from subclinical dogs - demonstrated by
xenodiagnostic techniques (exposure of infected dogs to parasite-free phlebotomine sand fly
bites under laboratory conditions). This unique technique has shown that the proportion of
infected sand flies is proportional to the severity of the clinical picture in exposed dogs. There
is also a positive correlation between the infecting power of sick dogs and the detection of high
serum antibody levels.

Tests that reveal a sub-clinically infected dog

Serology for anti-Leishmania antibodies is the first test to run to detect Leishmania infection in
a dog without clinical signs. A positive (even a low level) antibody test means that the dog has
been exposed to the parasite. Serology, however, is an indirect diagnosis and the only way to
demonstrate the infection is by evidence of the parasite. The most sensitive test is PCR to detect
parasite DNA. Obtain a sample from a lymph node and /or bone marrow fine needle aspirate to
provide the best material for increasing sensitivity of this molecular diagnostic technique.

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LEISHMANIOSIS

WHAT CLINICAL SIGNS

DOES A SICK DOG SHOW AND WHY?
Pathogenesis
Once infection is established in the dog, there are
two potential types of T-cell mediated immune
response that may develop.

The cellular response (Th1) or protective

immunity (essential to control the infection),
associated with production of low levels of
antibodies and activation of T cells (CD4+). T
cells mediate production of cytokines, such
as IFN-A, IL-2 and TNF-A, that stimulate
macrophages to increase activity and
produce nitric oxide, the main effector
capable of inducing parasite death.

The humoral (Th2) response is associated

with a reduction in cell-mediated immunity
and T-cell hypofunction (CD4+). This induces
production of interleukins (IL-4, IL-10) that
promote B lymphocyte stimulation with
production of high concentrations of non-
protective nonspecific gamma-globulins
(IgG, IgM, IgA and IgE). This response is
associated with disease progression and
there is a positive correlation between anti-
Leishmania antibody levels, parasitic load
and disease level.

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WHAT CLINICAL SIGNS DOES A SICK DOG SHOW AND WHY? LEISHMANIOSIS

The clinical signs of canine leishmaniosis result from

two pathogenic mechanisms:

Inflammatory process with development of

granulomas in the organs and tissues where the
parasite has multiplied.
Deposit of immune complexes (mainly
immunoglobulins G and M) in different organs.

Early signs
In the early stages of disease, clinical signs are mild:
lethargy, progressive weight loss, exercise intolerance,
lymphadenomegaly and mild skin lesions such as
alopecia and exfoliative dermatitis. Facial cutaneous exfoliative dermatitis lesions.

Progression
If adequate treatment is not instituted or the diseased dog has a non-protective immune response, then cutaneous
manifestations can develop including skin ulceration over bony prominences and mucocutaneous junctions.
Other signs indicating increasing severity Other, less common clinical signs have
are associated with immune complex been described:
deposits including: Fever
Vasculitis (e.g. nasal bleeding) Digestive disorders (ulcerative colitis)
Glomerulonephritis (with polyuria, polydipsia) Neurological (encephalitis)
Polyarthritis (erratic and sometimes Cardiorespiratory (pneumonitis, chronic rhinitis)
intermittent limping))
Eye lesions (conjunctivitis, kerato-uveitis,
retinopathies, etc.)

Plantar ulcers Nasal bleeding Keratouveitis

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WHAT CLINICAL SIGNS DOES A SICK DOG SHOW AND WHY? LEISHMANIOSIS

Prognostic factors
Clinical staging of canine leishmaniosis (as developed by the LeishVet group and used most frequently) is divided
into four stages (I – IV) based on clinical signs, quantitative serology, blood tests and urinalysis results. (Table) This
classification helps to determine an appropriate treatment protocol and establish a prognosis.

Canine leishmaniosis clinical staging (LeishVet) based on the International Renal Interest Society (IRIS)
staging for Chronic Kidney Disease (CKD)
Initial staging Serology Clinical signs Laboratory findings Prognosis
STAGE I Negative None
Mild clinical signs Good
Mild disease or low positive Renal profile NORMAL
Mild anemia, disproteinemia
STAGE II Low / high Two sub-stages:
Moderate Clinical Leishmaniosis Good / guarded
Antibody titers 1. Normal renal profile
disease
2. Slight proteinuria, creatinine <1.4 / UPC = 0.5 – 1

STAGE III Stage II + CKD

Medium / high
immune-mediated (vasculitis, ClIRIS I (UPC 1-5) or Guarded / poor
Severe disease Antibody titers
uveitis, arthritis...) IRIS II (creatinine 1.4 – 2.8 mg/dl)
STAGE IV IRIS III (creatinine 2.9 - 5 mg/dl)
Medium / high Stage III + nephrotic syndrome,
Very severe IRIS IV (creatinine > 5 mg/dl) or Poor / very poor
Antibody titers end stage CKD
disease Nephrotic syndrome (UPC > 5)

Recovery indications
In most cases, dogs classified in stages I and II have
a good clinical response (laboratory abnormalities return
to normal reference ranges and clinical signs resolve).
These dogs can remain in good health for a long time,
possibly years.

In contrast, dogs in the most advanced disease stages

(III and IV) have a reduced life expectancy due to
complications from chronic kidney disease, the leading
cause of death in canine leishmaniosis.

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LEISHMANIOSIS

WHAT DIAGNOSTIC TESTS SHOULD

BE RUN IN A DOG THAT IS SUSPECTED
TO HAVE THE INFECTION/DISEASE?
Rapid, table-side In hospital using microscope
Collect a detailed medical and epidemiological or similar equipment
history when presented with a suspected case of
Depending on the clinical picture, the parasite can be
canine leishmaniosis.
identified by evaluating a cytological sample from a
hematopoietic organ or skin or other tissue.
Conduct a complete physical examination with a
thorough assessment of: Lymph node, bone marrow, Skin, joint cavity, mucous
spleen… membranes…
Body condition
Mucous membranes
The most commonly performed procedure is fine needle
Palpation of lymph nodes
aspiration of external lymph nodes, with preparation
Examination of skin of smear, rapid Diff-quick stain, and subsequent
and mucocutaneous junctions microscopic evaluation. Finding amastigotes inside
macrophages confirms Leishmania infection.
If the clinical signs are compatible with canine
leishmaniosis, then carry out nonspecific tests (to
assess the general condition of the patient) and specific
tests (serology and fine needle aspiration for cytology/
molecular diagnosis) to uncover evidence of the parasite.

A round macrophage with many Leishmania infantum

amastigotes in the cytoplasm.

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WHAT DIAGNOSTIC TESTS SHOULD BE RUN IN A DOG LEISHMANIOSIS
THAT IS SUSPECTED TO HAVE THE INFECTION/DISEASE?

Laboratory testing
Basic laboratory tests The most common blood alterations Serum protein electrophoretogram
in canine leishmaniosis include: alterations are:
Complete blood count Mild non-regenerative Hyperproteinemia
Biochemical profile normocytic-normochromic with hyperglobulinemia and
(including serum protein anemia hypoalbuminemia, either
electrophoresis) Mild neutrophilia with compensatory or as a result
Urinalysis lymphopenia and monocytosis of renal proteinuria
(stress leukogram) In dogs with immune-mediated
Thrombocytopenia glomerulonephritis there will be
renal azotemia and proteinuria
Leukopenia (less common)

Specific technique

Include serological and parasitological diagnosis PCR provides improved sensitivity in the parasitological
(cytology and PCR). diagnosis of Leishmania infection in dogs.
Different methods have been developed using the
Available serological methods can be: nuclear genome or kinetoplast DNA (kDNA).
Qualitative (based on immunochromatography,
dot-ELISA) Methods that use kDNA appear to be more
sensitive for direct detection in infected tissues.
Easy to use in the clinic and yield a rapid
qualitative and specific result but have a
There are currently three PCR methods available:
variable sensitivity that is always lower
conventional PCR, nested PCR, and quantitative PCR.
than quantitative serology.

Quantitative (immunofluorescence-IFAT, enzyme-

linked immunosorbent assay-ELISA technique, PCR can be performed on DNA extracted from different
western blotting-WB). tissues, blood, biological fluids and even histological
material. Bone marrow, lymph node, spleen or skin are
There is a significant correlation between elevated the most sensitive tissues for PCR diagnosis while blood,
antibody titers and disease. buffy coat and urine significantly reduce the sensitivity
of this molecular diagnosis.

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WHAT DIAGNOSTIC TESTS SHOULD BE RUN IN A DOG LEISHMANIOSIS
THAT IS SUSPECTED TO HAVE THE INFECTION/DISEASE?

Test interpretation
Interpretation of the results in the diagnosis of canine leishmaniosis is essential because there are two types of
patients: clinically healthy infected dogs and sick dogs. The key to diagnosis is to properly differentiate these
two patients with the help of the results obtained.

HEALTHY CLINICALLY HEALTHY INFECTED SICK

PCR PCR PCR
Serology Serology
Serology (Low titers) (Medium-
high titers)
Clinical Clinical
signs Clinical
signs signs
Laboratory
Laboratory alterations Laboratory
alterations alterations

Interpretation of canine leishmaniosis diagnostic results: infected clinically healthy compared with sick dogs.

Acute vs convalescent
Canine leishmaniosis is a chronic disease and therefore
clinical signs do not become apparent until several
months or even years after the initial infection. One
exception to this occurs in dogs that develop localized
cutaneous leishmaniosis. This localized version of the
disease is characterized by papular lesions that usually
appear in hairless areas (pinna, lips, eyelids, around the
nasal planum, skin of the abdomen, etc.) These lesions
are known as “inoculation chancres”.

“Inoculation chancres”, lesions seen after the sand fly bites the ear
of a dog with canine leishmaniosis.

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LEISHMANIOSIS

WHAT GENERAL TREATMENT STRATEGY

IS RECOMMENDED FOR SICK DOGS?
Types of drugs to use
There are a limited number of drugs effective in the treatment of canine leishmaniosis. For decades, pentavalent
antimoniates (n-methyl glucamine) were almost exclusively used.

These work as a highly effective leishmanicide molecule by:

blocking the formation of ATP (adenosine triphosphate) and GTP (guanosine triphosphate).
increasing the phagocytic capacity of monocytes and neutrophils.

Short half-life 6-9 hours

Excreted two daily subcutaneous doses are recommended to maintain a

by kidneys higher inhibitory concentration

The second leishmanicide molecule is miltefosine, an alkyl phosphocholine.

Induces parasite apoptosis and stimulates T cell and macrophage activity

Long half-life 6-7 days leading to accumulation in plasma after repeated oral dosing

Excreted in feces no hepato-renal impact

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 CANINE
WHAT GENERAL TREATMENT STRATEGY LEISHMANIOSIS
IS RECOMMENDED FOR SICK DOGS?

The third drug used is allopurinol, a structural analog of hypoxanthine.

Inhibits ATP synthesis by altering pyrimidine metabolism and it is not considered a leishmanicide drug but a
leishmaniostatic.
Synergistic with previous leishmanicide molecules and current treatment protocols include it in combination with
antimonials or miltefosine, an approach that minimizes relapses. (Table)

Drug types to use for treating sick dogs based on the clinical staging
Seropositive dogs without clinical signs nor laboratory abnormalities:
Stage 0
no treatment needed

Monitor without treatment or treat with anti-Leishmania short term therapy

Stage I
(allopurinol, domperidone, nucleotides)

Antimoniate n-methyl glucamine 35-50 mg/kg s.c. /

Stage II 12h for 4 - 6 weeks plus allopurinol (6-12 months) OR Miltefosine 2 mg/kg
p.o. / 24h 4 weeks. + allopurinol

Allopurinol
Stage III-IV IRIS (www.iris-kidney.com) recommendations
Individual medical approach based on clinical signs

Monotherapy or combination therapy

In addition to the leishmanicides or leishmaniostatic drugs,
there are treatments available to enhance cellular immunity
including: domperidone, selected nucleotides and some
naturally occurring products currently under study. These may
be applied in combination with parasiticide drugs to amplify the
response to treatment of sick dogs and show promising results.
(Previous Table)

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 CANINE
WHAT GENERAL TREATMENT STRATEGY LEISHMANIOSIS
IS RECOMMENDED FOR SICK DOGS?

Supportive treatment strategies

In addition to specific treatments targeting the Leishmania From the second year onward
parasite, symptomatic treatment is also important. If the dog is stable, reduce to two check-ups per year and
then every 6-12 months after that as needed, depending
Ensure the dog receives a balanced palatable diet.
on the clinical course.
Further complementary treatments depend on the
clinical situation of each dog:
Management of co-infections
In dogs with skin lesions, application of anti- Outdoor dogs with high exposure to sand flies are
seborrheal baths, antiseptics, and fatty acids are also likely to suffer infestations from other arthropod
beneficial and improve their well-being. vectors, particularly ticks and fleas. Therefore, these
dogs commonly have Leishmania co-infection with
Kidney patients may benefit from polyvitamins, other pathogens.
anti-anemic, anti-hypertensives (ACEis) and a low-
protein diet. Ehrlichia canis, Hepatozoon canis, Anaplasma spp,
Dirofilaria spp. etc.

Monitoring for response

to treatment It is essential in the case of a suspected co-infection
to follow a comprehensive diagnostic plan including
Dogs under treatment with an appropriate protocol for a complete hematological and urinalysis to assess
their clinical and parasitological situation need to be the presence and define the impact of each pathogen
monitored. It is possible to monitor the parasitic load involved. Careful evaluation of all potential pathogens
using a quantitative PCR on bone marrow or lymph node will lead to implementation of the optimal concurrent
aspirates to assess the leishmanicidal efficacy of the treatment protocol.
treatment. These results may offer some relative value
in individual clinical cases and need to be validated.

30 days after treatment

Start with an initial check to evaluate the impact of
administered drugs.

During the first year

Recheck every 4 months including: physical examination,
blood count, hepatorenal biochemical profile, serum
protein electrophoresis and quantitative serology.
The infection to expect depends on the geographic distribution of
the vectors. In areas where the vectors and diseases coincide,
diagnosis can be complicated because some clinical signs are
common to several vector borne diseases.

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LEISHMANIOSIS

ARE OTHER PETS OR PEOPLE

IN THE HOUSE AT RISK?
The risks to people from an infected/sick dog
Both clinically healthy and sick infected dogs can live with people without increasing
the risk of transmission. People acquire the infection separately through the bite
of sand flies and therefore people who live in an endemic area where there are
infected dogs and sand flies are subjected to the same risks as their dogs.

Other public health considerations

In endemic areas, use of preventive measures against sand flies can reduce the
overall human disease risk. This can be achieved by applying effective repellents to
all dogs in the community. This approach reduces the reservoir dog population and the
chance of infection in sand flies. In addition, people can apply fly repellent treatments to
reduce their own chance of being bitten.

Can cats get this infection/disease?

The cat is a proven host in the Leishmania epidemiological cycle. Cats can be an infection
reservoir and can suffer from the disease. Most cases described in cats come from the
Mediterranean Basin and refer to L. infantum infection, while other Leishmania species in the
cat have been described as: L. brazilinesis, L. mexicana, L. venezuelensis, L. amazonensis,
L. tropica and L. major.

Feline leishmaniosis is a chronic disease and the

clinical signs and laboratory abnormalities can be
like those described in the dog, although cutaneous
forms predominate.
The diagnostic process is the same as for the dog and the most studied and
best tolerated treatment for the cat, so far, is allopurinol.

Xenodiagnostic studies confirm that sand flies feed on cats and transmit the
infection. Preventive measures for at-risk cats are therefore aimed at avoiding
sand fly bites by using an effective and safe sand flies repellent.

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LEISHMANIOSIS

WHAT ARE SOME RECOMMENDATIONS

AROUND PREVENTION STRATEGIES?
How to avoid the vector
The main route of Leishmania transmission is through a bite from the sand fly vector, and the best way to avoid
infection is through use of topical insecticides with proven anti-feeding efficacy against phlebotomine sand flies. These
insecticides are based on molecules with repellent and insecticide action and are available as collars, spot-on
pipettes, and sprayers. The synthetic pyrethroids are highly repellent molecules against these insects.

Collars Spot-on pipettes

Deltamethrin collars achieve maximum efficacy For topical application of permethrin in combination
one week after application and one collar can with active ingredients effective against other
provide protection for as long as 12 months. arthropods. Spot-on products can achieve good
Flumethrin-based collars can be effective for repellent efficacy against sand flies by 48 hours after
8 months. application and continue for 3-4 weeks.

Sprays can act immediately on application, but they do not have much residual effect and require weekly applications.
They may be recommended for use where there is a risk of immediate exposure. (Table).

Principle medication active ingredients with anti-feeding efficacy

that could prevent sand fly biting
Active Ingredient Formulation Time to efficacy onset Sand fly species

Deltamethrin Collar 7 days 12 months

Flumethrin +  Imidacloprid Collar 7 days 8 months

Permethrin + Imidacloprid Spot-on 24-48 hours 3-4 weeks

Permethrin + Fipronil Spot-on 24-48 hours 4 weeks

Permethrin + Dinotefuran Spot-on 24-48 hours

+ Piriproxyfen 4 weeks

Permethrin Spray Immediately 2-3 days

26
 CANINE
WHAT ARE SOME RECOMMENDATIONS LEISHMANIOSIS
AROUND PREVENTION STRATEGIES?

Is routine testing recommended?

Dogs living in canine leishmaniosis endemic areas should be given a serological test after the end of the sand
fly season. Generally, 3 months after the end of this risk season is advised to allow time to detect antibodies that
develop post-infection. Early diagnosis allows therapeutic measures to be applied as soon as possible with a greater
chance of full recovery.

Dogs living in non-endemic areas that travel to endemic areas should have serology run within a few months (3-4)
of returning home.

General thoughts on preventive treatments

Vector borne disease control is always challenging. Vector control in the environment
using chemical methods (e.g. periodic fumigation) is an almost impossible task given
the complex vector biology and the potential for negative impacts on other animal
species and the local ecosystem. Physical barriers in homes are recommended
including the installation of mosquito nets in windows and the use of insecticide-
impregnated mosquito net fabrics around beds during the high-risk season. In addition,
it is advisable to avoid and remove favorable sand fly habitat by cleaning up decaying
organic matter. Finally, keep dogs inside the house during peak sand fly activity times
(dusk to dawn) to reduce the transmission risk.

Is there a vaccine?
There are currently three different vaccines available
(one in Brazil and two in Europe).

One of the European vaccines is produced from

excretion/secretion antigens from L. infantum
(LiESP/QA-21) promastigote cultures and is
adjuvanted with a purified fraction of saponin
(Quillaja saponaria, QA-21).
The second European vaccine contains a
recombinant protein of L. infantum MON-1
(Q protein), derived from genetic fusion of five
antigenic fragments obtained from four
The vaccine in Brazil is based on a recombinant
intracellular Leishmania proteins.
antigen (A2), from L. donovani, and has
demonstrated 71% protection in field studies.

27
 CANINE
WHAT ARE SOME RECOMMENDATIONS LEISHMANIOSIS
AROUND PREVENTION STRATEGIES?

Field studies used for registration of these vaccines report an efficacy of 68.4% and 72%, respectively. (Table)

Vaccines against canine leishmaniosis

Composition Recombinant antigen (A2) E/S antigens Recombinant Protein Q
L. donovani L. infantum (LiESP/QA-21)

Reported Efficacy 71.4% 68.4% 72%

Indication Seronegative dogs ≥ 6 months Seronegative dogs ≥ 6 months Seronegative dogs ≥ 6 months

Serology test before

Rapid test Rapid test IFAT / ELISA
vaccination

Administration 3 doses (every 3 weeks) 3 doses (every 3 weeks) 1 dose

Onset of Immunity 30 days post 3rd dose 30 days post 3rd dose 30 days post 1st doce

Duration of Immunity 12 months 12 months 12 months

DIVA Vaccine No No Yes

Vaccines can be administered to seronegative dogs over six months of

age and have a duration of immunity of 12 months, so annual boosters
are recommended.

None of the three vaccines can prevent L. infantum infection

in vaccinated dogs which means that the use of
repellents is essential in endemic areas, or in dogs
traveling in the area. Vaccination enhances active
cellular immunity in dogs that provides protection
if they acquire the infection.

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LEISHMANIOSIS

WHAT DOES THE FUTURE LOOK LIKE?

What are the changes being seen with the disease?

There has been an exponential advancement in canine leishmaniosis knowledge over the past three
decades with many related publications in scientific journals. This research is helping to better
understand canine leishmaniosis to improve the life expectancy of affected dogs.

Studies in immunology and an improved knowledge of the dog’s immune response to infection, have led
to development of new molecules and techniques for treatment (immunomodulatory), diagnosis (PCR)
and prevention (repellents, vaccines) and helped to design better strategies for control.

Despite these advances, the disease endemic range continues to increase and canine
leishmaniosis is no longer confined to the Mediterranean basin and to Brazil, historically
the areas of greatest risk. The disease has been imported, and/or autochthonous cases
have been documented, in many countries in Central and Northern Europe and Central
and South America. Widespread and frequent movement of people and animals together
with climate change favoring the sand fly vector are the main triggers for these important
epidemiological changes.

Is the risk of disease increasing?

The risk of infection with Leishmania continues to expand because there is an increase in density of
both the hosts (dogs, wild canids, other reservoirs) and the vector. In addition, increasing temperatures
associated with climate change extend the period of activity
of sand flies alarmingly.

In the Mediterranean basin, the period of sand fly activity was previously limited to 3-4 months
of summer through early autumn but has now expanded to exceed 8 months and in some areas
sand flies are now active almost year-round. This extended activity considerably increases the
risk of transmission.

29
 CANINE
WHAT DOES THE FUTURE LOOKS LIKE? LEISHMANIOSIS

Has resistance to prevention or reduced

treatment effect been seen?
The therapeutic arsenal against Leishmania is scarce and resistance has been reported to most of the
actives used to treat human leishmaniosis (antimonials, amphotericin B, miltefosine, paromomycin).
In veterinary medicine there is evidence of resistance to antimonials and allopurinol, but mechanisms
producing resistance are not well known.

Resistance is not necessarily synonymous with therapeutic failure and it is necessary to analyze
each report of apparent “resistance” because there are factors linked to the parasite (species,
pathogenicity), the host (immune response, genetics) and the drug used (dose, tolerance, efficacy)
that can be at play.

No resistance has been reported to synthetic pyrethroids used as anti-feeding treatments that
prevent sand fly bites and therefore Leishmania infection transmission. Apparent efficacy failure
may be more likely a result of non-compliance or inadequate use. All cases of apparent efficiency
reduction should be appropriately monitored and reported to the product manufacturer
and health authorities.

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LEISHMANIOSIS

FURTHER READING
Bibliography
Baneth G et al. Canine leishmaniosis - new concepts Maia C and Cardoso L. Spread of Leishmania
and insights on an expanding zoonosis: part one. infantum in Europe with dog travelling. Veterinary
Trends in Parasitology 24 pp 324 - 30 2008. Parasitology 213 pp 2 - 11 2015.

Boggiatto PM et al. Transplacental transmission Millán J et al. Role of wildlife in the epidemiology
of Leishmania infantum as a means for continued of Leishmania infantum infection in Europe,
disease incidence in North America. PLoS Neglected Parasitology Research 113 pp 2005 - 2014 2014.
Tropical Diseases 5 p e1019 2011.
Miró G et al. Canine leishmaniosis, new concepts
de Freitas E et al. Transmission of Leishmania infantum and insights on an expanding zoonosis: part two.
via blood transfusion in dogs: potential for infection Trends in Parasitology 24 pp 371 - 377 2008.
and importance of clinical factors. Veterinary
Parasitology 137 pp 159-167 2006. Miró G et al. Novel areas for prevention and control
of canine leishmaniosis. Trends in Pararasitology 33
Gálvez R et al. Controlling phlebotomine sand flies pp 718 - 730 2017.
to prevent canine Leishmania infantum infection: A
case of knowing your enemy. Research Veterinary Naucke TJ et al. First report of transmission of
Science 121 pp 94-103 2018 canine leishmaniosis through bite wounds from a
naturally infected dog in Germany. Parasites and
Grinnage-Pulley T et al. A Mother’s Gift: Congenital Vectors 9 p 256 2016.
Transmission of Trypanosoma and Leishmania
Species. PLoS Pathog. 12 p e1005302 2016. Petersen CA and Barr SC. Canine leishmaniasis in
North America: emerging or newly recognized?
Karkamo V et al. The first report of autochthonous Veterinary Clinics of North America Small Animal
non-vector-borne transmission of canine Practice 39 pp 1065 - 1074 2009.
leishmaniosis in the Nordic countries. Acta
Veterinaria Scandinavica 56 p 84 2014. Quilez J et al. Genetic control of canine
leishmaniasis: genome-wide association study and
Koch LK et al. Modeling the climatic suitability of genomic selection analysis. PLoS One 7 p e35349
leishmaniasis vector species in Europe. Scientific 2012.
Reports 17 7 p 13325 2017.
Ready PD. Leishmaniasis emergence and climate
Koutinas AF et al. Clinical considerations on canine change. Rev Sci Tech 27 pp 399 - 412 2008.
visceral leishmaniasis in Greece: a retrospective
study of 158 cases (1989-1996). Journal of the dos Santos Nogueira F et al. Use of miltefosine
American Animal Hospital Association 3 pp 376 - to treat canine visceral leishmaniasis caused by
383 1999. Leishmania infantum in Brazil. Parasites & Vectors
12 p 79 2019.

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FURTHER READING LEISHMANIOSIS

da Silva SM et al. First report of vertical

transmission of Leishmania (Leishmania infantum)
in a naturally infected bitch from Brazil. Veterinary
Parasitology 166 pp 159 - 162 2009.

Solano-Gallego L et al. Prevalence of Leishmania

infantum infection in dogs living in an area of
canine leishmaniasis endemicity using PCR on
several tissues and serology. Journal of Clinical
Microbiology 39 pp 560-563 2001.

Solano-Gallego L et al. LeishVet guidelines for the

practical management of canine leishmaniosis.
Parasites & Vectors 4 p 86 2011.

Svobodova V et al. Canine leishmaniosis in three

consecutive generations of dogs in Czech Republic.
Veterinary Parasitology 237 pp 122-124 2017.

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DIROFILARIASIS