Leishmaniasis
Group of protozoal diseases caused by:
• L. Donovani - Visceral Leishmaniasis • L. tropica Cutaneous L. Anthroponotic C L (ACL) Zoonotic C L (ZCL) • L. Brazilliensis - Muco - Cutaneous L.
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Transmitted by bite of female Phlebotomine Sand fly. Phlebotomus argentipes – vector of L. Donovani causing kala-azar [ VL]. P. Papatasi & P. Sergenti - vectors of L. Tropica causing Oriental sore [ CL]
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VL: India, Bangladesh, Nepal, Sudan, Brazil CL: Afghanistan, Pakistan, Iran, Syria Saudi Arabia, Algeria, Brazil, Peru MCL: Bolivia, Brazil, Peru
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Problem statement
• • • • Overall prevalence 13 million cases Total population at risk 350 million Annual incidence 1.8 million Associated with HIV infection – 1 -9 % of AIDS cases have acquired / reactivated VL • 9/10 cases of VL occur in Bangladesh, Brazil, India & Sudan
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INDIA
• Plains of Ganges and Brahmaputra • Bihar, West Bengal Eastern UP & Assam, NEPAL 12 Terai districts adjoining Bihar, W.B. 5.6 million people at risk From 1980 to 2006 : 21, 837 cases reported 297 Deaths CFR - 1. 3%
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AGENT - Morphology
Life Cycle: Insect host & vertebrate host
Promastigote • Insect • Motile • Midgut
Amastigote
• Mammalian stage • Non-motile • Intracellular
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Promastigote
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Amastigote
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Leishmania (LeishmanDonovan or LD bodies). Lying in macrophage cells from liver
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A macrophage filled with Leishmania amastigotes.
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Reservoirs
• RODENTS and CANINE • India and Nepal VL is non-zoonotic and MAN is the only RESERVOIR HOST FACTORS: • All age groups • Males • Population movement- Migrant labourers • Affects “Poorest of Poor”
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OCCUPATION: Farming, forestry, mining, fishing Immunity: Long lasting ENVIRONMENTAL FACTORS: Seasonal pattern April-September Confined to plains Rural Areas-breeding places for sand fly
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VECTORS
Phlebotomine Sandflies VL- P. argentipes CL- P. papatasi, P. sergenti Highly Anthropophilic Breeds in cracks and crevices of soil and buildings, tree holes, caves etc Development projects expose people to vector : Forest clearing, Cultivation projects, Water resources schemes
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Transmission
1. Bite of an infected SANDFLY Inoculation of promastigotes 2. Contamination of bite wound by crushing insect while feeding. 3. Blood transfusion. Extrinsic Incubation Period - 6-9 days
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VL - Clinical Manifestation
Incubation Period: 10 days – 2 years
Low grade, irregular fever Hepato-splenomegaly Extreme Cachexia Anaemia Progressive muscular Atrophy
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VL - Clinical Manifestation
Indian VL – KALA AZAR Darkening of skin in face, hands, feet & abdomen Bone marrow hyperplasia, Epistaxis , Hematuria Lab . Tests: Leucopenia, Proteinuria, Hypergammaglobulinaemia
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Course of Visceral Leishmaniasis
Fatal [ if untreated ] > 90% Major causes of death: 1. Secondary infections, 2. sepsis 3. Hemorrhages
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• Profile view of a teenage boy suffering from visceral leishmaniasis. The boy exhibits splenomegaly, distended abdomen and severe muscle wasting.
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Post Kala Azar Dermal Leishmanoid (PKDL)
India & Sudan Develops years after recovery Multiple nodular infiltrations of skin Restricted to skin
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PKDL
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PKDL
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Cutaneous L [ Oriental sore ]
• Painful ulcers in exposed body parts. • Restricted to Skin. • Reduces victims ability to work.
Mucocutaneous L.
• Around mouth & nose, • Mutilating lesions, • Victims may become social outcaste.
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Cutaneous leishmaniasis of the face.
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Cutaneous leishmaniasis lesion on the arm
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Mucocutaneous Leishmaniasis
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Mucocutaneous Leishmaniasis
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Diagnosis
Clinical signs & symptoms Laboratory investigations: Haemoglobin, TLC , Reversed Albumin: Globulin ratio WBC: RBC is 1 : 1500 Parasitological diagnosis: Bone marrow biopsy, Spleen or liver biopsy Look for LD bodies
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Diagnosis
• Serology: • ELISA, • Indirect Fluorescent Antibody Test [ IFAT ] • Field test: Direct Agglutination Test (DAT) • Field test: Anti-K39 strip-test
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Skin: Leishmanin test. [Montenegro test] Aldehyde test of Napier
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Treatment
Good nursing care Adequate nutrition Vitamin supplements & iron Hydration Treatment of secondary infections
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Antibiotics
1.Pentavalent antimonials- Sodium stibogluconate. 2.Amphotericin B 3.Liposomal Amphotericin B 4.Paromomycin 5.Miltefosine (Oral)
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Sodium stibogluconate (IV or IM) • IV 20 mg / kg / d x 20 days • Cure rate 90-95% • Resistance in Bihar • Side effects: Myalgia, arthralgia, arrhythmia,
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Amphotericin B • 1 mg/kg/d as IV infusion for 4 weeks • Cure rate 96-100% • Side effects: fever, rigors • Hospitalisation / monitoring necessary
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Miltefosine : First oral drug. • 2.5 mg / kg / d in 2 divided doses x 4 weeks. • Cure rate 94-96% • Nausea, vomiting, diarrhea • Contraindicated in pregnancy • Outpatient compliance? • Resistance formation ? (DOT)
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Liposomal Amphotericin B • 3 mg / kg / day x 5 days • Cure rate 93-97% • No side effects • Compliance assured • Very expensive Paromomycin • 16-20 mg /kg /d IM x 21 days • Cure rate 93-97% • Pain at injection site
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Response to treatment
Within 2 weeks 90% patients show: • Weight gain • Absence of fever • Definite rise of Hb, leucocytes and platelets • Decreased spleen size (but may persist for months) • Absence of parasites
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Control of Kala-Azar
VECTOR CONTROL:
Residual Insecticide spraying - DDT or BHC 2 rounds / year, 1-2 grams / sq. mtr Human dwellings, animal shelters and resting places up to 6 feet from ground Sanitation measures to eliminate breeding places
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RESERVOIR CONTROL:
MAN: Active and passive case detection by house-to-house surveys. Treatment of cases
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FOLLOW UP
Ideally, follow up month 1, 3, 6, 12
• Inform on signs of PKDL • Inform of signs of relapse (5-10%) i.e. weight loss, fever, increasing spleen size
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Personal Prophylaxis
Health education Individual protective measures Avoid sleeping of floor, Use fine mesh nets around bed Use insect repellants
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Kala Azar control Program In Nepal
OBJECTIVES 1. To reduce morbidity and mortality due to Kala-Azar, 2. To determine the efficacy of the firstline drug Sodium stibogluconate. 3. To prevent epidemics due to Kalaazar.
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STRATEGIES
1. Early diagnosis and prompt treatment of Kala-azar cases through strengthening of referral services at the peripheral health institutions, 2. Establishment of appropriate laboratory diagnostic facilities, 3. Early detection and timely containment of Kala-azar epidemics,
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STRATEGIES
4. Protection of at-risk population with indoor residual spraying, 5. Promotion of health education for community awareness 6. Training of HP In-charges, PHOs, DHOs and Medical Officers 7.Conducting field research on the epidemiology of Kala-azar, vector bionomics and effectiveness of anti-Kala-azar drugs
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