SR. NORAZSIDA RAMLI
BLOOD & TISSUE
There are 4 morphologic forms seen in
-they can exist in two or more of the 4
morphologic forms depending on the
Species: donovani , tropica, mexicana,
1) Cutaneous leishmaniasis: a localized infection
of the capillaries of the skin.
2) Mucocutaneous leishmaniasis: cause lesions
of the skin and mucous membranes,
specifically of the oral and nasal mucosa.
3) Visceral/sistemic leismaniasis: more
generalized symptoms leading to enlargement
of the internal organs, especially the liver,
lymph nodes and spleen.
Indistinguishable in appearance.
Differentiated based on:
- Geographic distribution.
- Kinetoplast DNA (kDNA) analysis
- DNA hibridization
- Serologic testing.
Divided into 4 groups:
1) Leishmania tropica complex – Old World
2) Leishmania mexicana complex – New
World Cutaneous Leishmaniasis.
3) Leishmania braziliensis complex –
4) Leishmania donovani complex – Visceral
Stage of life
Only have 2 stages of life:
Size: 5 by 3µm
Shape: oval to
Consisting of dot-like
small axoneme and
Shape: long and
end of the organism,
Leishmania tropica complex – Old
World Cutaneous Leismaniasis.
L. tropica - mediterranean region, middle East,
Armenia, Caspian region, Afghanistan, India and
Kenya (particularly in urban areas)
L. aethiopica – Highlands of Ethiopia, Kenya and
L. major – Desert regions of Turkmenistan,
Uzbekistan and Kazakhstan, Northern Africa and
the Sahara, Iran, Syria, Israel and Jordan.
Cause a chronic disease: cutaneous
Also known as Oriental sore, Delhi boil
and dry or urban cutaneous leishmaniasis.
Characterized by: production of dry,
raised, ulcerated lesions at bite sites.
Vectored by: tiny sandflies of the genera
Vector: Phlebotomus sandfly
Sandfly vs mosquito
Only the female sandfly transmits the parasites.
Vector draws a blood meal from an infected host
amastigotes form transform into
promastigotes n multiply (within fly gut)
promastigotes migrate to the pharynx fly
feeds again, transmitted to a new host
engulfed by reticuloendothelial cells
amastigotes multiply repeatedly by binary
fission. cell ruptures amastigotes invade
new macrophages and perpetuate the cycle.
Transmission & Pathogenesis
Incubation period vary from several weeks to as
First sign of cutaneous leishmaniasis= the
development of a small red papule at the initial
site of the insect bite.
A local granulomatous response leads to the
formation of a crateriform lesion 2cm or more.
L. tropica n L. aethiopica produce dry lesions.
L. major produce moist lesions with a serous
Lesions can heal spontaneously but may leave
Contact spread of infection also possible.
Patient may produce multiple sores by
scrathing and autoinoculating normal skin.
Diffuse cutaneous leishmaniasis (DCL):
-occur in anergic patient (who is unable to
amount an adequate immune respon).
-characterized by the presence of multiple
nodular lesions, particularly on the face
-loaded with parasites and do not heal
Montenegro (leishmanin) skin test
-delayed hypersensitivity reaction provoked by a
suspension of killed leishmanial promastigotes
-local inflammatory reaction appears at the site of
injection within 48-72 hours.
Molecular diagnostic technique- PCR
Serologic test – ex: indirect fluorescent antibody
Sodium stibogluconate (antimony sodium
Use of bed netting
Insect repellent and residental spraying
Rodent control in reducing transmission.
Individuals with active lesions promptly
treated, wound covered to prevent
autoinfection and further insect
transmission to other individuals.
Leishmania mexicana complex –
New World Cutaneous
L. mexicana – Belize, Guatemala, and the
L. pifanoi – Amazon river basin and parts
of Brazil and Venezuela.
L. amazonensis – Amazon basin of Brazil.
L. venezuelensis – forests areas of
L. garnhami – Venezuelan Andes.
Distribution extends from Southern Texas in the
United states, through Mexico, Central and South
L. mexicana causes chiclero ulcer or Bay sore.
L. pifanoi causes DCL.
L. amazonensis causes cutaneous and DCL.
L. venezuelensis causes cutaneous leishmaniasis.
L. garnhami causes Venezuelan Andean
Transmitted by Lutzomiya sandfly
Reservoir host: rodents, opossums,
domestic dog, cat etc.
Life cycle same with L. mexicana complex.
Vector: Lutzomiya sandfly
Transmission & Pathogenesis
L. mexicana - produces a lesion known as
chiclero ulcer or Bay sore – common
among workers who collect chicle gum
from the Chicazapote trees in the rain
forest in Nicaragua, Guatemala, Belize
and the Yucatan peninsula of Mexico.
Clinical manifestation: a single cutaneous
papule, nodule or ulcer located on the ear
or face. Lesion generally heal
spontaneously but may cause cartilage
destruction and gross disfigurement.
L. pifanoi and L. amazonensis – produce a
single but more likely to progress to the
DCL – the majority patient infected,
clustered in the Amazon river Basin of
Brazil and Venezuela.
Clinical presentation of DCL may be
confused with Leptomatous Leprosy.
L. garnhami and L. venezuelensis –
assosiated with cutaneous leishmaniasis
in rural parts of Venezuela – infection with
either organism present with a solitary
lesion that is usually self-limiting.
Picture: Mildly elevated indurating nodules are seen on the face
and extremities (gross findings).
Giemsa stained smears –amastigotes will
Cultivation – promastigotes forms can be
Immunological testing methods.
In most cases, the infections are self-
limiting and require no treatment.
Treatment is paramount if:
-the lesion should endure or
-threaten cartilaginous structures; ear,nose.
Therapeutic agents: same as the
treatment of Oriental sore.
Same as the prevention ways of Oriental
applied insect repellent to the skin and
garments along with aerial spraying.
Leishmania braziliensis complex –
L. braziliensis – Mexico to Argentina
L. panamensis – Panama and Columbia
L. peruviana – Peruvian Andes.
L. guyanensis – Guiana and parts of Brazil
Cause infections throughout the Americas
from Mexico to Argentina.
The distinguishing feature of these
infectious is the development of ulcers on
or about the oral and nasal mucosa
L. braziliensis causes espundia.
L. guyanensis causes pain bois.
L. peruviana causes uta.
All cause considerable morbidity and
mortility in the endemic areas.
Same with L. mexicana complex
Vector: Lutzomyia and Psychodopygus
The primary lesion-same manner as the Oriental
sore: macrophage ingest the parasites
become heavy laden with replicating
amastigotes tissue damage.
Invade mucous membranes of the mouth and
Spread by: direct extension of the primary lesion
or metastasis via the bloodstream or lymphatics.
Progression of disease may take years.
Resulting disease: may produce ulcers
that erode soft tissues of the face and
palate or form polyp-like appendages in
the nasal cavity.
Patient commonly present with
enlargement of the regional lymph nodes
and secondary bacterial infections.
Untreated patients generally succumb
to these secondary infection or to
starvation if destruction of the oral cavity is
By demonstrating amastigotes of
Leishmania in Giemsa stained smears or
biopsy material from the edge of an active
Montenegro skin test.
Sodium antimony (Pentostom).
Cycloguanil pamoate (Camolar).
Amphotericin B (Fungizone).
Personal protective measures such as
:protecting clothing, insect repellents and
Reservoir host control
Public health educational programs.
Prompt treatment of infected individuals
to break the cycle of disease transmission.
Leishmania donovani complex –
L. donovani – India, Pakistan, Thailand,
parts of Africa and the Peoples Republic of
L. infantum – Mediterranean area, Europe,
Africa, the Near East, and parts of the
former Soviet Union.
L. chagasi – Central and South America.
Visceral leishmanisis also known as Kala Azar
or dum-dum fever.
The most severe of the Leishmaniasis.
Generally a disease of juveniles and young
Natural reservoir: rodents and dog.
In India, man appears to be the only mamalian
L. donovani complex –parasitize the
reticuloendothelial cells, viscerotropic, infected
macrophages remaining fixed or disseminate
throughout the body.
In the Mediterranean are, Europe, Africa,
Soviet union – Phlebotomus sandfly
remains the vector. Natural reservoir:
domesticated dogs, canines and
In the New World (Central and South
America) – Lutzomiya sandfly remains the
vector. Natural reservoir: Foxes, domestic
dogs and cats.
Same with L. mexicana complex.
The infected mononuclear phagocytes do not
remain confined to the skin or mucous
Parasitized macrophages are carried by the
bloodstream to lymphoid tissue throughout the
body especially to the spleen, liver and bone
Amastigotes multiply in great numbers in this
Vectors: Phlebotomus sandfly and Lutzomiya
Transmission & pathogenesis
Transmitted by sandflies.
Incubation period: 3 weeks to 2 years.
The infected macrophages migrate by
lymphatic and hematogenous spread to
distant lymphoid tissues throughout the
Transmission via blood transfusion is also
Early symptoms: prodome of headache,
malaise, fever, possible weight loss and
Fever may occur in periodic intervals mimicking
tertian or quartan malaria.
Another symptoms: diarrhea, consistent with
typhoid fever, enlargement of liver and spleen
(hepatosplendomegaly) and lymph nodes
(lymphadenopathy), and increase in serum
Microscopically, parasitized macrophages may
be found in the tissue of the spleen, liver, heart,
kidneys, lymph nodes, intestines and bone
Rapid proliferation of reticuloendothelial
cells within the involved organs lead to
Parasitized macrophages may crowd out
other hematopoietic cells leading to
various degrees of anemia and
The infiltration of the intestinal mucosa
may result in ulceration and yield
malabsorption, and wasting.
As the patient become more emaciated,
the abdominal distention from the
hepatosplenomegaly becomes more
A characteristic hyperpigmentation of the
forehead and hands, known in India as
Kala Azar, may also be observed.
The prognosis for untreated cases is poor.
Mortality rate cab be as high as 95%.
In chronic cases, death ususally occurs
from medical complications or bacterial
infections within 2 years of diagnosis.
With treatment, the prognosis is usually
Recovering leads to a lasting immunity.
In some patients, a condition called post-
kala azar dermal leishmaniasis, or dermal
leishmoid, may develop following the
treatment with antimony compounds.
The clinical presentation of this condition
is marked by the appearance of either
erythematous or hypopigmented lesions
anywhere on the body.
A butterfly rash is a characteristic of
systemic lupus erythemous. – may
develop on the malar portion of the face.
The dermal lesions, whether a papule or
patch, may progress to nodules and
resemble lepromatous leprosy.
These lesions do contain viable parasites
and can serve as a reservoir of infection.
Direct examination of stained smears.
Direct agglutination test (DAT).
Complement fixation test (CF).
Indirect fluorescence technique.
Molecular diagnostic technique.
Montenegro skin test (not reactive in people with
Pantavalent antimony sodium gluconate
Pentamidine isothionate (Lomidine)
Allopurinol + Pentostom
Gamma interferon + Pentostom.
Same with the others leishmania sp.
been fixed in