BLOOD AND TISSUE BLOOD AND TISSUE FLAGELLATESFLAGELLATES

General Characters:General Characters:

1.1. They live in blood and tissue of a They live in blood and tissue of a human host.human host.

2.2. They need a vector I.H. for They need a vector I.H. for transmission.transmission.

3.3. They move by a single flagellum arise They move by a single flagellum arise from kinetoplast. The kinetoplast is from kinetoplast. The kinetoplast is formed of parabasal body and formed of parabasal body and blepheroplast.blepheroplast.

4.4. They multiply by longitudinal binary They multiply by longitudinal binary fission (the kinetoplast divides first fission (the kinetoplast divides first followed by the cytoplasm).followed by the cytoplasm).

5.5. They may take They may take one of the one of the

following forms:following forms:

Promastigote:Promastigote:

EpimastigotEpimastigote: e:

TrypomastigTrypomastigote:ote:

Amastigote:Amastigote:

6. They include: 6. They include: LeishmaniaLeishmania, , Trypanosoma, Trypanosoma, Plasmodium, Plasmodium, Toxoplasma, Toxoplasma, Babesia. Babesia.

Visceral leishmaniasisVisceral leishmaniasisLeishmania donovaniLeishmania donovani complex complex is the causative organism is the causative organism

ofofvisceral leishmaniasis (Kala_Azar, black sickness or visceral leishmaniasis (Kala_Azar, black sickness or

dumdumdumdumfever).fever).

There are 3 members in this group:There are 3 members in this group:

Leishmania infantumLeishmania infantum:: causing infantile kala-Azar in the causing infantile kala-Azar in the Mediterranean region, Middle East, parts in Africa and Mediterranean region, Middle East, parts in Africa and China.China.

Leishmania donovaniLeishmania donovani:: in India, East Africa and China. It in India, East Africa and China. It is common among young adults.is common among young adults.

Leishmania chagasiLeishmania chagasi:: in South America. It is common in South America. It is common among children below the age of four years old.among children below the age of four years old.

Morphology:Morphology:

1- Amastigote:1- Amastigote: in in tissue of man:tissue of man:

Amastigote Amastigote (leishmanial(leishmanial

form) is oval andform) is oval and

measures 2-5 measures 2-5 microns bymicrons by

1 - 3 microns.1 - 3 microns.

2- Promastigote:2- Promastigote: in in thethe

vector I.H. or vector I.H. or culture.(NNN culture.(NNN Medium)Medium)

It measures 14 It measures 14 –– 20 20

microns by microns by

1.5 - 41.5 - 4  microns.microns.

D.H.D.H. Man, dogs and rodents. The dogs and Man, dogs and rodents. The dogs and rodentsrodents

are act as reservoir hosts.are act as reservoir hosts.

Vector of transmission:Vector of transmission: Female sand fly genus Female sand fly genus phlebotomus.phlebotomus.

Epidemiology: Epidemiology:

Leishmaniasis is prevalent world wide: Leishmaniasis is prevalent world wide: rangingranging

from south east Asia, Indo-Pakistan,from south east Asia, Indo-Pakistan,

Mediterranean, north and central Africa, and Mediterranean, north and central Africa, and southsouth

and central America.and central America.

Life cycle:Life cycle:

The The LeishmaniaLeishmania life life

cycle is considered acycle is considered a

cyclopropagative lifecyclopropagative life

cyclecycle (change in the (change in the

form and increase inform and increase in

the number).the number).

Mode of infection:Mode of infection: byby

a bite of infecteda bite of infected

female sand fly.female sand fly.

Pathology:Pathology:

Leishmania donovani Leishmania donovani is a parasite of the R.E.S.is a parasite of the R.E.S.

When the promastigotes from the infected When the promastigotes from the infected female sand fly are inoculated into the skin they female sand fly are inoculated into the skin they are engulfed by the macrophages and change are engulfed by the macrophages and change into amastigotes and start multiplication.into amastigotes and start multiplication.

The infected macrophages pass to the blood The infected macrophages pass to the blood and all the viscera where the amastigotes and all the viscera where the amastigotes invades and multiply in the R.E.S. e.g. spleen, invades and multiply in the R.E.S. e.g. spleen, liver, bone marrow, lymph nodes, kidney, liver, bone marrow, lymph nodes, kidney, intestineintestine…………etc.etc.

Clinical Picture:Clinical Picture:

I.P varies between few weeks to few I.P varies between few weeks to few months.months.

High or low grade intermittent fever.High or low grade intermittent fever. Toxemia, anorexia and loss of weight.Toxemia, anorexia and loss of weight. Hepatosplenomegaly, jaundice and Hepatosplenomegaly, jaundice and

disturbed liver functions (reversed disturbed liver functions (reversed A/G ratio 1:2 as the globulin increases A/G ratio 1:2 as the globulin increases and the albumin decreases). and the albumin decreases).

N.B. the normal ratio is 2:1.N.B. the normal ratio is 2:1. Anemia, leucocytopenia due to bone Anemia, leucocytopenia due to bone

marrow suppression.marrow suppression.

Lymphadenopathy.Lymphadenopathy.

Glomerulonephritis and dysentery Glomerulonephritis and dysentery with leishmania bodies in the urine with leishmania bodies in the urine and stool.and stool.

Naso-pharyngeal granuloma.Naso-pharyngeal granuloma.

Skin: in visceral leishmaniasis, it takes 2 Skin: in visceral leishmaniasis, it takes 2 forms:forms:

a- Leishmanoma:a- Leishmanoma: a skin nodule at the site a skin nodule at the site of bite resulted from multiplication of the of bite resulted from multiplication of the amastigotes in the skin macrophages.amastigotes in the skin macrophages.

b- Post Kala-Azar Dermal Leishmanoid b- Post Kala-Azar Dermal Leishmanoid (PKDL):(PKDL): it is a skin condition appears after it is a skin condition appears after recovery and characterized by the presence recovery and characterized by the presence of multiple depigmented macules on the of multiple depigmented macules on the exposed parts of the face and limbs. These exposed parts of the face and limbs. These macules change to nodules which never macules change to nodules which never ulcerate. Amastigotes appear in smear from ulcerate. Amastigotes appear in smear from the nodules.the nodules.

N.B.N.B. PKDL appears due to the recovery of PKDL appears due to the recovery of

thethe suppressed cell mediated immune response. suppressed cell mediated immune response.

Diagnosis:Diagnosis:

I- Clinical:I- Clinical: Fever, hepatosplenomegaly, anemia, leucopenia Fever, hepatosplenomegaly, anemia, leucopenia and leishmanoma. and leishmanoma.

II- LaboratoryII- Laboratory

A. Direct diagnosis:A. Direct diagnosis:

1- Demonstration of the organisms (amastigotes) in:1- Demonstration of the organisms (amastigotes) in: Blood by blood film with thick film.Blood by blood film with thick film. Spleen by splenic puncture.Spleen by splenic puncture. Liver by liver biopsy.Liver by liver biopsy. Bone marrow by puncture biopsy.Bone marrow by puncture biopsy.

2- Culture in the NNN media: (Novy-Mc Neal and Nicolle)2- Culture in the NNN media: (Novy-Mc Neal and Nicolle)The PROMASTIGOTE FORM IS GROWN ON CULTURE ON The PROMASTIGOTE FORM IS GROWN ON CULTURE ON

NNN medium.NNN medium. It is formed of agar base + defibrinated rabbit blood + NaCl It is formed of agar base + defibrinated rabbit blood + NaCl

+ Penicillin + Streptomycin.+ Penicillin + Streptomycin.

3- Animal inoculation: inoculation of the specimen in Hamster 3- Animal inoculation: inoculation of the specimen in Hamster then the spleen and liver will be examined after 6 months.then the spleen and liver will be examined after 6 months.

B. Indirect diagnosis:B. Indirect diagnosis:

1- Blood examination: 1- Blood examination: anemia, leucopenia and anemia, leucopenia and reversed A/G ratio.reversed A/G ratio.

2- I.D. Test (Montenegro or Leishmanin Skin 2- I.D. Test (Montenegro or Leishmanin Skin Test): Test): the test is negative during the active the test is negative during the active infection and it turns to positive after infection and it turns to positive after treatment as a result of the recovery of the cell treatment as a result of the recovery of the cell mediated immunity.mediated immunity.

3- Formal Gel Test: 3- Formal Gel Test: 1 cc patient serum + 1 1 cc patient serum + 1 drop of commercial formalin --- it will be solid drop of commercial formalin --- it will be solid and opaque in 20 min in positive cases.and opaque in 20 min in positive cases.

4- Urea Stibamine Test: 4- Urea Stibamine Test: Patient serum + 24% Patient serum + 24% urea stibamine ----- white ring at the interface.urea stibamine ----- white ring at the interface.

5- IFAT.5- IFAT. 6- ELISA.6- ELISA. 7- CFT.7- CFT.

Treatment: Treatment:

Pentavalent antimony compounds:Pentavalent antimony compounds: Pentostam 600 mg / day / 6 days IM Pentostam 600 mg / day / 6 days IM or IV.or IV.

Diamidine compounds:Diamidine compounds: Pentamidine Pentamidine 4 mg / kg BW / 10 days.4 mg / kg BW / 10 days.

Control:Control:

Treatment of patients.Treatment of patients. Control of vector.Control of vector. Destruction of reservoir hosts.Destruction of reservoir hosts.

Cutaneous Leishmaniasis of Cutaneous Leishmaniasis of Old WorldOld World

(Oriental sore, Delhi ulcer, Baghdad boil, Allepo boil)(Oriental sore, Delhi ulcer, Baghdad boil, Allepo boil)

Distribution:Distribution: Mediterranean area, Sudan, Mediterranean area, Sudan, Ethiopia,Ethiopia,

KSA, Iran, Iraq, India.KSA, Iran, Iraq, India.

Habitat:Habitat: R.E.S found in the skin.R.E.S found in the skin.

Morphology, Vector, Life cycle inside the Morphology, Vector, Life cycle inside the vector:vector:

the same as Leishmania donovani but it is onlythe same as Leishmania donovani but it is only

localized in the skin in a form of cutaneous localized in the skin in a form of cutaneous ulcer.ulcer.

LeishmaniaLeishmania Vector Vector

LeishmaniaLeishmania Vector Vector

Human

cycle

Animal

reservoir

vector

Pathology:Pathology:

When the promastigotes from the infected When the promastigotes from the infected female sand fly are inoculated into the skin female sand fly are inoculated into the skin they are engulfed by the macrophages and they are engulfed by the macrophages and change into amastigotes and start change into amastigotes and start multiplication.multiplication.

The infected macrophages attract other The infected macrophages attract other macrophages, plasma cells, lymphocytes macrophages, plasma cells, lymphocytes leading to a nodule formation that leading to a nodule formation that undergoes necrosis and ulceration. The undergoes necrosis and ulceration. The ulcer has indurated raised edges ulcer has indurated raised edges surrounded by red area. It also contains surrounded by red area. It also contains necrotic base and sometimes secondary necrotic base and sometimes secondary bacterial infection. The ulcer heals within 6-bacterial infection. The ulcer heals within 6-12 months.12 months.

Clinical Types of Cutaneous Leishmaniasis:Clinical Types of Cutaneous Leishmaniasis:

1- Leishmania tropica (Urban, chronic, dry 1- Leishmania tropica (Urban, chronic, dry type):type):

It is distributed in the Middle East, South It is distributed in the Middle East, South of USSR, India and other parts of Asia.of USSR, India and other parts of Asia.

The hosts (D & R) are man and dogs The hosts (D & R) are man and dogs (Anthroponotic).(Anthroponotic).

It takes a long IP (2-4 M).It takes a long IP (2-4 M). The ulcer is chronic with slow ulceration The ulcer is chronic with slow ulceration

and usually it is a single dry ulcer. The and usually it is a single dry ulcer. The parasites are present in the edges.parasites are present in the edges.

The lesion heals after 1-2 years.The lesion heals after 1-2 years. Immune response is cellular (ID test is Immune response is cellular (ID test is

positive)positive)

2- Leishmania major (Rural, acute, moist 2- Leishmania major (Rural, acute, moist type):type):

It is distributed in the North and It is distributed in the North and Central Africa.Central Africa.

The reservoir hosts are the rodents The reservoir hosts are the rodents (Zoonotic).(Zoonotic).

It takes a short IP (2-4W).It takes a short IP (2-4W). The ulcer is acute with rapid ulceration, The ulcer is acute with rapid ulceration,

it may be single or multiple wet ulcers it may be single or multiple wet ulcers with perfuse discharge.with perfuse discharge.

Healing is rapid as it takes 3-6 months.Healing is rapid as it takes 3-6 months. Immune response is cellular (ID test is Immune response is cellular (ID test is

positive).positive).

Cutaneous Cutaneous leishmaniasisleishmaniasisCutaneous Cutaneous

leishmaniasisleishmaniasis

3- Leishmania aethiopica 3- Leishmania aethiopica (Diffuse type):(Diffuse type):

It is distributed in Ethiopia and It is distributed in Ethiopia and Kenya.Kenya.

The reservoir hosts are wild The reservoir hosts are wild rodents.rodents.

It is extensive as a result of the It is extensive as a result of the suppressed immune response.suppressed immune response.

The ulcers are wet type.The ulcers are wet type. ID test is negative as a result ID test is negative as a result

of the suppressed immune of the suppressed immune response.response.

Disseminated Disseminated cutaneous cutaneous

leishmaniasisleishmaniasis

Disseminated Disseminated cutaneous cutaneous

leishmaniasisleishmaniasis

4- Leishmania recidiva (Relapsing or 4- Leishmania recidiva (Relapsing or LupoidLupoid

type):type):

It is distributed in the Middle East, It is distributed in the Middle East, South of USSR, India and other parts South of USSR, India and other parts of Asia.of Asia.

The hosts are man and dogs (D &R).The hosts are man and dogs (D &R). It is a chronic lesion resulted from It is a chronic lesion resulted from

exaggerated immune response.exaggerated immune response. The lesion starts on the face and The lesion starts on the face and

spread gradually giving a butter fly spread gradually giving a butter fly appearance as lupus vulgaris.appearance as lupus vulgaris.

Diagnosis:Diagnosis:

I. Clinical:I. Clinical:

The ulcer may be The ulcer may be singlesingle

or multiple on theor multiple on the

exposed area of theexposed area of the

body. body.

They are suspected inThey are suspected in

the patients comingthe patients coming

from endemic areas.from endemic areas.

II. Laboratory:II. Laboratory:

Direct:Direct: Smear:Smear: Skin biopsy:Skin biopsy: Culture: on Culture: on

NNN mediaNNN media PCR:PCR:

Indirect:Indirect:

Intradermal Intradermal test.test.

Treatment: Treatment:

Pentavalent antimony compounds: Pentavalent antimony compounds: Pentostam 600 mg / day / 6 days Pentostam 600 mg / day / 6 days IM or IV or local injection.IM or IV or local injection.

Refampicin and Metronidazole.Refampicin and Metronidazole.

Cryosurgery and ulcer excision.Cryosurgery and ulcer excision.

Cutaneous and Mucocutaneous Cutaneous and Mucocutaneous Leishmaniasis of New WorldLeishmaniasis of New World

Geographical Distribution:Geographical Distribution: Central Central and Southand South

America.America.

Vector:Vector: Lutozomyia.Lutozomyia.

D.H.:D.H.: Man.Man.

R.H.:R.H.: Wild animals and rodents.Wild animals and rodents.

Leishmania mexicana:Leishmania mexicana: It is a It is a cutaneous form of Leishmania and it cutaneous form of Leishmania and it resembles the Leishmania tropica in resembles the Leishmania tropica in the pathology and the clinical picture.the pathology and the clinical picture.

Leishmania braziliense:Leishmania braziliense: It is the It is the mucocutaneous form of Leishmania: it mucocutaneous form of Leishmania: it starts as a skin nodule that ulcerates starts as a skin nodule that ulcerates and extends to the mucous membrane and extends to the mucous membrane of the nose, mouthof the nose, mouth……..etc...etc.

Mcutaneous Mcutaneous leishmaniasisleishmaniasisMcutaneous Mcutaneous

leishmaniasisleishmaniasis

Diagnosis, treatment and Diagnosis, treatment and prevention:prevention: as as Leishmania tropica.Leishmania tropica.

Dawoud H, Linss G, judge C, Steuber Dawoud H, Linss G, judge C, Steuber S, S, KruegerKrueger

D D (1998): A case OF cutaneous (1998): A case OF cutaneous leishmaniasis inleishmaniasis in

A German patient in Frankfurt/Oder.A German patient in Frankfurt/Oder.

Hyg. Mikrobiol. 2: 43.Hyg. Mikrobiol. 2: 43.

Immunity against Immunity against LeishmaniasisLeishmaniasis

I. Cutaneous and Mucocutaneous I. Cutaneous and Mucocutaneous Leishmaniasis:Leishmaniasis:

It is mainly cellular by It is mainly cellular by macrophagesmacrophages and and lymphocyteslymphocytes, as the macrophages , as the macrophages engulf the invading parasites and engulf the invading parasites and release chemotactic substancesrelease chemotactic substances which which attract other macrophages and attract other macrophages and lymphocytes.lymphocytes.

Humoral immune response plays a Humoral immune response plays a minimalminimal role. role.

The cellular immune response varies The cellular immune response varies from a from a minimal responseminimal response as in as in Leishmania aethiopicaLeishmania aethiopica to to exaggerated exaggerated responseresponse as in as in Leishmania recidivaLeishmania recidiva. In . In between the other to forms (dry and between the other to forms (dry and wet wet Leishmania tropicaLeishmania tropica) exist.) exist.

The cellular immune response The cellular immune response demonstrated by demonstrated by Montenegro skin testMontenegro skin test..

Infection give long lasting protection Infection give long lasting protection as reinfection is rare but it might occur as reinfection is rare but it might occur in immune suppression. in immune suppression.

II. Visceral Leishmaniasis:II. Visceral Leishmaniasis:

The cellular immune response is The cellular immune response is suppressedsuppressed during the during the active diseaseactive disease and and it is reactivated after the treatment. So, it is reactivated after the treatment. So, Montenegro skin test is negative during Montenegro skin test is negative during the activity of the disease and it turns to the activity of the disease and it turns to positive after treatment.positive after treatment.

Humoral immune response is Humoral immune response is eexxaaggggeerraatteedd with production of polyclonal IgG.with production of polyclonal IgG.

Infection give long lasting immunity Infection give long lasting immunity against reinfection. against reinfection.