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.
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 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
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.