LEISHMANIASIS

A chronic systemic infectious disease transmitted by the bite of a sand fly.

Cause

  • Flagellated protozoa Leishmania species

Clinical features

Visceral Leishmaniasis (Kala-azar)

  • Chronic disease characterized by fever, hepatosplenomegaly, lymphadenopathy, anaemia, leucopenia, progressive emaciation and weakness
  • Fever of gradual onset, irregular, with 2 daily peaks and alternating periods of apyrexia
  • The disease progresses over several months and is fatal if not treated
  • After recovery from Kala-azar, skin (cutaneous) leishmaniasis may develop

Cutaneous and Mucosal Leishmaniasis (Oriental sore)

  • Starts as papule, enlarges to become an indolent ulcer
  • Secondary bacterial infection is common

Differential diagnosis

  • Other causes of chronic fever, e.g. brucellosis
  • (For dermal leishmaniasis) Other causes of cutaneous lesions, e.g. leprosy

Investigations

  • Stained smears from bone marrow, spleen, liver, lymph nodes, or blood to demonstrate Leishman Donovan bodies
  • Culture of the above materials to isolate the parasites
  • Serological tests, e.g. indirect fluorescent antibodies
  • Leishmanin skin test (negative in Kala-azar)

Management

Cutaneous Leishmaniasis (all patients)

  • Frequently heals spontaneously but if severe or persistent, treat as for Visceral Leishmaniasis below

Visceral Leishmaniasis (Kala-azar): All patients

  • Combination: Sodium stibogluconate 20 mg /kg per day IM or IV for 17 days
  • Plus paromomycin 15 mg/kg [11 mg base] per day IM for 17 days

Alternative first line treatment is:

  • Sodium Stibogluconate 20 mg/kg per day for 30
    days (in case paromomycin is contraindicated)
    In relapse or pregnancy
  • Liposomal amphotericin B (e.g. AmBisome) 3
    mg/kg per day for 10 days

In HIV+ patients

  • Liposomal amphotericin B 5 mg/kg per day for
    8 days

Post Kala-Azar Dermal Leishmaniasis (PKDL)

  • Rare in Uganda
  • Sodium Stibogluconate injection 20 mg/kg/day until clinical cure. Several weeks or even months of treatment are necessary

Note

  • Continue treatment until no parasites detected in 2 consecutive splenic aspirates taken 14 days apart
  • Patients who relapse after a 1st course of treatment with Sodium stibogluconate should immediately be retreated with Ambisome 3 mg/kg/day for 10 days

Prevention

  • Case detection and prompt treatment
  • Residual insecticide spraying
  • Elimination of breeding places