|Clinical Guidelines and Treatment Manual (MSF, 1993, 319 p.)|
|Chapter 6 - Parasitic diseases|
Parasitic infection of humans and certain animal hosts caused by flagellate protozoans, Leishmania spp, transmitted by the bite of infected female Phlebotomus sandflies. Two major forms:
- Cutaneous and mucocutaneous leishmaniasis
· Old World, also known as oriental sore (also by many other local names). Occurs in the Middle East, Mediterranean, Ethiopia, India.
· New World, also known as espundia or mucocutaneous form, occurs in South America and Africa (Ethiopia...).
- Visceral leishmaniasis, or Kala-Azar
· Occurs in the Middle East, Mediterranean, India, East Africa, China, Latin America.
CUTANEOUS LEISHMANIASIS (ORIENTAL SORE)
AND MUCOCUTANEOUS LEISHMANIASIS (ESPUNDIA)
- Incubation 2 to 4 months; single or multiple lesions appear on exposed areas of skin. Starts as a papule, which then extends in circumference and depth to form a crusty ulceration (dry form).
- Wet forms tend to evolve more quickly.
- Lesions tend to resolve spontaneously, leaving a scar.
- Lesion can extend to mucus membranes (mouth, nose, conjuntivae) and can be very mutilating (mucocutaneous form).
- Persistent fever, pallor, anemia, weight loss, hepatomegaly, splenomegaly; sometimes adenopathy, diarrhea and hemorrhage.
- Raised ESR, raised gammaglobulins.
- If untreated, is invariably fatal.
- Serology: test for Kala-Azar (direct agglutination, clot Elisa. Always confirm by looking directly for parasites. Serology is of no value in cutaneous forms (false -, false +).
- By indentification of Leishmania from skin lesions (cutaneous forms), or from blood, bone marrow, lymph nodes or spleen (kala-azar).
- May-Grunwald-Giemsa stain: parasites are intracellular and seen within histiocytes.
- The main drugs are antimony compounds:
meglumine antimonate(amp 5 ml = 1.5 g in IM): 50 mg/kg/d x 10 to 15 days
sodium stibogluconate (amp. 1 ml = 100 mg in IM or IV):
Child under 5 years:
Child 5 to 14 years:
Duration of 30 days, except with Indian kala-azar which is treated for 6 days only.
· Idiosyncratic reactions: fever, chills, cough, myalgia and rash. These reactions can be fatal so stop therapy if any of these symptoms appear.
· Therapy must be closely supervised as toxicity may appear late and is serious. Signs of toxicity are: fever, chills, cough, rash, polyneuritis, cardiac failure and renal failure.
- pentamidine (amp. 3 ml = 120 mg in IM): 2 to 4 mg/kg x 6 injections every 48 hours The patient should be supine during and after the injections as they can cause either hypoglycaemia or hyperglycaemia.
- Cutaneous leishmaniasis
Both meglumine antimonate and sodium stibogluconate promote healing but are not without danger.
· Systemic meglumine antimonate (course of IM injections) can be reserved for serious cases.
· For single lesions, or a small number of small lesions, local therapy can be tried instead. Give 1 to 3 ml of meglumine antimonate injected around and beneath the lesion, to be repeated if necessary.
- Visceral leishmaniasis
Either meglumine antimonate or sodium stibogluconate are given
systematically as described above. Strict supervision is necessary.
In case of poor response or idiosyncratic drug reaction, use pentamidine.
Vector control and, in some cases, control of animal reservoir.