Leishmaniasis
Aashrith Garlapati Roll :03
Contents
01 05
Introduction Lab diagnosis
02 06
Problem Statement Treatment
03 07
Epidemiological Control measures
determinants
04
Clinical features
Introduction
● Group of protozoal diseases caused by parasites of the genus
Leishmania
● They are transmitted to the man, by the bite of the female
Phlebotomine sandfly.
VL Visceral Leishmaniasis
● It causes a variety of syndromes in man, which include:
CL Cutaneous Leishmaniasis
MCL muco-cutaneous Leishmaniasis
ACL Anthroponotic cutaneous leishmaniasis
ZCL Zoonotic cutaneous leishmanisis
PKDL post kala azar dermal leishmaniasis
● Their visceral type of disease, kala-azar, is still an important disease in
India.
● Majority of the leishmaniasis are zoonoses involving wild/domestic
(rodents, canines). Some forms (Indian kala-azar) are considered to be
also non zoonotic infections.
Problem Statement
WORLD:
It is endemic in many countries in tropical and subtropical regions.
3 mains diseases are distributed as follows:
1) Visceral Leishmaniasis (VL) : Known as Kala-azar is fatal in over 95% of cases. Most cases occur in Brazil, East
Africa and South-east Asia. An estimated 90,000 new cases of VL occur worldwide each year.
2) Cutaneous Leishmaniasis (CL) : Most common form of leishmaniasis and causes skin lesions, mainly ulcers on
exposed parts of the body. About 95% occur in the Americas, Mediterranean region , Middle east, Central Asia. It
is estimated that about 1 million new cases occur annually.
3) Muco-cutaneous Leishmaniasis (MCL): Leads to partial destruction of mucous membranes of nose, mouth, throat.
Over 90% of cases occur in South america.
Kala- azar is worsening due to the occurrence of asymptomatic cases, PKDL, undernutrition, and kala-azar/HIV
coinfection. Case fatality rate has decreased in some countries due to improved management.
India: Kala-azar is endemic in 54 districts . About 130 million population is at risk of disease.
Epidemiological determinants of Kala-azar
Agent Factors
• Kala-azar is caused by the Leishmania species, which are intracellular protozoan parasites.
• Causative species:
• Leishmania donovani → Visceral leishmaniasis (Kala-azar)
• Leishmania tropica → Cutaneous leishmaniasis
• Leishmania braziliensis → Mucocutaneous leishmaniasis
• These forms are not strictly distinct—cutaneous forms can visualize and vice versa.
• Life cycle:
• Occurs in two hosts:
• Humans (vertebrate host): Amastigote form (Leishman-Donovan bodies)
• Sandfly (insect host): Promastigote form (flagellated)
• No cross-immunity between species.
Reservoirs of Infection
• Animal reservoirs: Dogs, jackals, foxes, rodents and other mammals.
• In India, kala-azar is considered non-zoonotic—humans are the only known reservoir.
👤 Host Factors
• Age:
Affects all age groups, but peak incidence in children aged 5–9 years.
• Sex:
Males are affected twice as often as females.
• Population movement:
Migrants, laborers, and tourists can introduce infection to new areas.
• Socio-economic status:
Affects the poorest populations.
Poor housing, open sewerage, and waste accumulation promote sandfly
breeding.
Overcrowding and sleeping outdoors/on ground increase exposure.
• Malnutrition:
Deficiencies in protein-energy, iron, vitamin A, and zinc increase disease
progression risk.
• Occupation:
High-risk in farming, forestry, fishing, and mining due to outdoor exposure.
• Immunity:
Recovery confers long-lasting immunity.
During active disease, cell-mediated immunity is suppressed
(evidenced by negative leishmanin skin test).
🌍 Environmental Factors
• Altitude:
Mostly confined to areas below 600 meters.
• Seasonality:
Two peaks: November and March–April.
High prevalence during and after monsoon.
• Climate and ecological changes:
Rainfall changes, land degradation, deforestation, and climate change impact vector survival.
Drought, floods, and famine → trigger migration and malnutrition, increasing susceptibility.
• Rural predominance: More common in rural areas with suitable breeding sites for sandflies.
• Vector: Transmitted by Phlebotomus sandflies (P. papatasi, P. sergenti).
• Sandflies breed in cracks/crevices in soil,
Clinical Features:
● Mode of transmission :
- Bite of female phlebotomine sandfly, P.argentipes.
- May also take place by contamination of the bite wound or by contact when the insect is
crushed during feeding
- P.sergenti transmits cutaneous leishmaniasis
- Blood transfusions, contaminated syringes have also been a mode of transmission.
● Incubation period:
- Extrinsic incubation period: After an infective blood meal, the sandfly becomes infective
from 4-25 days. (Time taken for parasite to develop inside the vector)
- In man the period is often between 1-4 months. The range is 10 days to 2 years.
CLINICAL FEATURES
1) Kala- Azar (VL): Classical features are: fever, splenomegaly and hepatomegaly
accompanied by anemia and weight-loss.
Darkening of the skin of the face, hands , feet and abdomen is common in India. (kala-azar =
black sickness)
Atypical features of the diseases include lymphadenopathy. It has a high mortality rate if not
treated immediately.
Post Kala azar Dermal Leishmaniasis: It is caused by L.donovani and is common in India. It
appears several years after cure of kala - azar. Key feature is lesions without ulcerations, with
parasites in the lesions. Multiple nodular lesions are seen on the skin. Hence its called dermal
leishmaniasis.
CLINICAL FEATURES:
2) Cutaneous Leishmaniasis: Several forms are seen such as ACL/ZCL/DCL . It may be
mistaken for leprosy. The agent is restricted to the skin. Diseases is characterized by painful
ulcers in parts of body exposed to sandfly bites, reducing a victims work capability.
3) Muco-cutaneous Leishmaniasis: Ulcers similar to the oriental sores around the margin of
mouth and nose. it can mutilate the face so badly that victims may become social outcasts.
LAB DIAGNOSIS:
1) Rapid Diagnostic Test (rk39 dipstick test) :
• Based on recombinant k39 antigen, detects antibodies
against Leishmania donovani.
• Simple, quick (5 mins), but not reliable for relapse,
reinfection, or HIV co-infections.
• Presence of a red line indicates a positive result; control line
should always appear to validate the test.
2) Parasitological Diagnosis:
• Demonstration of Leishman-Donovan (LD) bodies in spleen, liver,
bone marrow, lymph node aspirates.
• It is the gold standard for confirming Visceral Leishmaniasis (VL)
and Cutaneous Leishmaniasis (CL).
3) Aldehyde Test (Napier’s Test):
• Uses serum mixed with 40% formalin; a positive result shows
jellification.
• Useful for field diagnosis but non-specific and mainly used for
surveillance.
4) Serological Tests
• Includes Direct Agglutination Test (DAT), rk39 dipstick, ELISA, IFAT.
• ELISA is useful for large-scale surveys; IFAT and DAT are reliable for
diagnosis.
5) Leishmanin (Montenegro) Test
• Intradermal test measuring delayed hypersensitivity using
Leishmania antigen.
• Positive in CL and MCL after recovery but not useful in active VL
cases.
• Helps in epidemiological studies by identifying immune status.
6) Hematological Findings
• Shows progressive leucopenia, anemia, hypoalbuminemia, and
raised ESR.
• Increased IgG levels with a reversed Albumin:Globulin ratio.
• New ICMR dipstick test (2014) detects the parasite in saliva or urine
with visible red bonds for positive cases.
Treatment Guidelines for kala azar:
1) First-line treatment:
• Liposomal Amphotericin B (LAMB):
• Single IV dose of 10 mg/kg body weight.
• Safe for all age groups, pregnant & lactating women, elderly, PKDL, HIV co-infection.
2) Miltefosine Capsules:
• Adults (12–65 years): 50 mg twice daily after meals for 28 days.
• Children (2–11 years): 2.5 mg/kg once daily after meals for 28 days.
• Not given to pregnant/lactating women and women refusing contraception.
3)Amphotericin B Deoxycholate Injection:
• IV dose: 1 mg/kg body weight on alternate days.
• Total: 15 infusions over 30 days.
4)Combination Therapy:
• Miltefosine + Paromomycin IM (15 mg/kg) for 10 days.
5) HIV Co-infected Patients:
• LAMB 40 mg/kg in 4 divided doses on days 1, 5, 10, 17, 24, 31, and 38
6) PKDL (Post Kala-azar Dermal Leishmaniasis):
• First choice: Miltefosine 100 mg orally per day × 12 weeks.
• Alternative: Amphotericin B Deoxycholate 1 mg/kg bw over 4 months (60–80 doses).
7. Order of Drug Preference:
1. LAMB single dose (10 mg/kg)
2. Combination regimens (e.g.,
Miltefosine + Paromomycin)
3. Amphotericin B Emulsion
4. Miltefosine capsule
5. Amphotericin B Deoxycholate
(multiple doses)
6. Amphotericin B Emulsion
(selected districts)
8. Miltefosine Dosage Charts:
• Dosage guides for:
• Children (2–11 years): Based
on body weight (e.g., 20 mg daily for 9–
11 kg).
• Persons >12 years: Based on
weight (>25 kg gets 50 mg twice daily,
<25 kg gets 50 mg once daily).
CONTROL MEASURES
CONTROL OF RESERVOIR
• Humans are the only reservoir in most endemic areas.
• Active and passive case detection and proper treatment are key.
• House-to-house visits and mass surveys for early detection help control disease.
• In areas with animal reservoirs (e.g., dogs), appropriate measures against them
are needed (e.g., dog and rodent control programmes).
CONTROL MEASURES
SANDFLY CONTROL
• Application of residual insecticides, especially DDT, is effective against sandflies.
• DDT is the first choice as the vector (P. argentipes) is susceptible.
• Spraying should cover all human dwellings, shelters, and animal areas up to a height
of 6 feet (2 meters).
• Use DDT at rate of 1–2g per square meter (repeat 2 rounds per year).
• If resistance is seen, change insecticide (Benzene Hexachloride as second line).
• Spraying must be repeated regularly to reduce sandfly density.
• Combine insecticidal spraying with sanitation measures:
• Eliminate breeding places (cracks, rodent burrows, rubbish). Improve sanitation
measures.
• Keep animal shelters (cattle sheds, poultry) distant from human houses.
CONTROL MEASURES
PERSONAL PROPHYLAXIS
Reduce risk of infection through health education and individual protective
measures:
• Avoid sleeping on the floor.
• Use fine-mesh nets around bed.
• Apply insect repellents (lotions, creams, sticks) for temporary protection.
• Keep personal environment clean.
• No drugs available for personal prophylaxis.
THANK
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