Infectious Disease Compendium

Leishmania

Microbiology

A protozoa, there are numerous species depending on where it was acquired. There is old world predominantly L. donovani and New World, of which there are TNTC.

Epidemiologic Risks

Old World: India, Mideast, Asia and N. Africa.

New World: All over C. and S. America. Spread by the sand fly. Coming North with global heating (PubMed).

Syndromes

Cutaneous: a large, ragged, dry ulcer at the site of the bite, 2 weeks to 2 months after the bite. With L. braziliensis, the mucous membranes can be involved to cause destruction of the nose, face etc.

Kala-azar or visceral disease: fever, weight loss, hepatosplenomegaly, anemia, and leukopenia. It can be a major problem in AIDS patients. It sounds like a Ricardo Montalban character who fights Kirk.

Treatment

The ins and outs of Leishmania are too complicated for this guide; the few cases I have treated have always been with the help of the CDC.

Stibogluconate sodium 20 mg/kg /day for 20 to 28 days. Some Indian strains are resistant, perhaps due to arsenic in the water (Read about it).

Liposomal Amphotericin B (10 or 20 mg/kg single dose is the preferred treatment for visceral disease and should cure 95% (PubMed,PubMed)), ketoconazole 400 - 600 mg qd and itraconazole have activity against some Leishmania.

Fluconazole 5 mg/kg per day cured 75% of patients and 8 mg/kg per day, the cured 100% of Leishmania (Vianna) braziliensis in Brazil (PubMed).

Paromomycin 11 mg per kilogram of body weight intramuscularly qd for 21 days is noninferior to Ampho B for visceral leishmaniasis (kala-azar) (PubMed).

Miltefosine is used in the Indian subcontinent, but resistance may be increasing (PubMed) with one in 5 failing therapy (PubMed).

With cutaneous disease, pentoxifylline 400 mg po tid for 30 days (PubMed) increases healing and decreases relapse and in one small study (PubMed) rimiquimod 7.5% cream administered topically every other day for 20 days, intravenous meglumine antimoniate 20 mg/kg per day every day for 20 days was superior to either agent alone.

For cutaneous L. major topical paromomycin-gentamicin or paromomycin alone daily for 20 days ((15% paromomycin–0.5% gentamicin cream) or paromomycin alone (15% paromomycin cream)) are effective (PubMed).

Heat is also effective for cutaneous Leishmania major (Plos).

Notes

If you suspect a case, call the CDC. They are extremely helpful, will aid in getting the ulcer cultured and help guide therapy. Invaluable.

ICD9 Codes (Soon to be supplanted by ICD10)

Leishmaniasis 085.9; American 085.5, cutaneous 085.4, mucocutaneous 085.5; Asian desert 085.2; acute necrotizing 085.2; Brazilian 085.5; cutaneous 085.9; dermal

Leishmaniasis, cutaneous; diffuse 085.3; dry form 085.1; Ethiopian 085.3; eyelid 085.5 ; eyelid 085.5 [373.6]; infantile 085.0; late 085.1; lepromatous 085.3; Mediterranean 085.0; mucocutaneous (American) 085.5; naso-oral 085.5; nasopharyngeal 085.5; Old World 085.1; post kala-azar 085.0; recurrent 085.1; rural 085.2; ulcerating 085.1; urban 085.1; visceral (Indian) 085.0; wet form 085.2; zoonotic form 085.2.