Leishmaniasis

– Parasitic diseases of humans and many animals caused by protozoa of the genus Leishmania, transmitted by the bite of sandflies.

– Cutaneous leishmaniasis is found in southern Europe, Asia (Middle East, Afghanistan, Pakistan) in Africa and Latin America.

– The mucocutaneous leishmaniasis occurs in Latin America and more rarely in Africa (Ethiopia, Sudan).

– Visceral leishmaniasis or kala-azar occurs in East and North Africa, Asia (India, Pakistan, Bangladesh, Nepal, China), in southern Europe and

Latin America.

Clinical signs :

Cutaneous leishmaniasis and mucocutaneous:

– Lesion (s) single or multiple on exposed parts: papule that extends in surface and depth to form a crusted ulcer in dry forms.

Wet forms evolve faster and are more damaging.

– Evolution towards spontaneous healing most often at the cost of greater or smaller scar. Lesions may also spread to the mucous membranes (mouth, nose, conjunctiva) and be very disfiguring. This is the mucocutaneous form.

Visceral leishmaniasis:

– Fever of any type (persistent, undulating, with peaks) and splenomegaly are the main signs 2. Weight loss, lymphadenopathy are common. Other signs: epistaxis, pallor, anemia, hepatomegaly, diarrhea.

– In the absence of treatment, progression to death.

Dermatitis post-kala azar:

Dermatitis of unknown origin occurring after the treatment of visceral leishmaniasis.

Mucous membranes can be achieved. For severe forms, one by systemic treatment identical to that of visceral leishmaniasis may be required (derivatives of antimony, paromomycin).

Laboratory:

– Review parasitological:

• tissue biopsy in the peripheral portion of the ulcer for cutaneous forms or

• puncture-aspiration of the spleen, lymph nodes or bone marrow for the visceral form (splenic aspiration is the most sensitive test but carries a theoretical risk of potentially fatal bleeding) and

• identification of Leishmania on sprawl, coloring May-Grünwald

Giemsa: free or sometimes intracellular parasites (in a macrophage).

– Serology ELISA and IFAT. There are direct agglutination tests used in the field when we do not have a laboratory.

– For visceral leishmaniasis: elevated ESR and pancytopenia.

Treatment :

The different species of Leishmania respond variably to the drugs used. Comply with the national protocol. For information :

Cutaneous leishmaniasis and mucocutaneous:

– Forms single lesion or lesions few: start with a local treatment with a derivative of antimony: meglumine antimoniateor sodium stibogluconate, 1-3 ml injected at the base of the lesion, to renew according to the clinical outcome. IM route is reserved for severe cases and should be used under strict medical supervision.

– Mucocutaneous forms: treat immediately systemically, as for visceral leishmaniasis with meglumine antimoniate orsodium stibogluconate or amphotericin B (see below).

Visceral leishmaniasis:

– Start by treatment with a derivative of antimony:

meglumine antimoniate IM (81 mg Sb5 + / ml) or IM sodium stibogluconate (100 mg Sb5 + / ml)

Doses expressed as antimony, are the same for the two products:

Children and adults: 20 mg / kg / day for 30 days

– Symptomatic treatment of fever, anemia (iron + folic acid), frequent intercurrent infections (malaria, dysentery, pneumonia, etc.). Aggressive treatment is needed. A HIV infection may also be present.

– Hydration, protein-calorie diet.

Treatment of 2nd intention for non response to antimony derivatives:

– Paromomycin (aminosidine) IM

Children and adults: 15 mg / kg / day for 21 days associated with a restatement by the derivatives of antimony at the doses indicated above.

Paromomycin may also be used alone, dosage and duration of treatment vary according to the protocols.

– Liposomal amphotericin B (less toxic than amphotericin B) strictly IV infusion in 5% glucose to pass in an hour:

Children and adults: The total dose given during a full treatment is usually 24 mg / kg in 6 injections of 4 mg / kg / injection once a day for 6 days or a day on 2 for 2 weeks.

Start with a dose of 1 mg IV slowly (10-15 minutes) to test for allergic reactions and patient tolerance.

in the absence of,

– Amphotericin B IV infusion in 5% glucose to spend 4 hours:

nephrotoxic active drug but do not exceed the dose indicated.

Children and adults: start with a dose of 1 mg IV slowly (20-30 minutes) to test for allergic reactions and patient tolerance. Gradually increase by increments of 5 to 10 mg / day to a dose of 0.5 to 1 mg / kg / day maximum, administer one day 2. The total dose given during a full treatment is usually 20 mg / kg.

– Pentamidine IM slow deep (to administer to a patient in the supine position):

but can use more toxic and less effective as derivatives of antimony.

Children and adults: 4 mg / kg / injection every other day 2 for a total treatment duration of 5 to 25 weeks, until disappearance of the parasite on microscopic examination (for visceral leishmaniasis, 2 puncture-aspiration to negative 14 days apart).