Leishmaniasis is a zoonotic disease caused by protozoa, which belongs to the genius Leishmania. Mode of transmission is effected by the bite of phlebotomites (sand flies) from animals to humans. It has two major clinical forms: visceral and cutaneous leishmaniasis.

• Visceral Leishmaniasis (Kalazar): It's cardinal manifestations include fever, marked weight loss, splenomegally and features of pan-cytopenia:

• Cutaneous Leishmaniasis: This form is characterized by the development of single or multiple firm, erythematuos papule which occur on the exposed part of the body. It may ulcerate later in the course of the illness.

Diagnosis

It requires the demonstration of the organism by smear or culture of aspirates or tissue. Serological tests like ELISA and direct agglutination tests are very helpful.

Treatment

General:

Supportive care includes treatment of concomitant infections and blood transfusions

Specific:

A. Visceral Leishmaniasis:

First line:

Sodium stibogluconate 20 mg/Kg/day given iv or im in a single dose for 28 consecutive days. Therapy should be repeated using the same dose for another 40 to 60 days in -patients with relapse or incomplete response.

S/E: nausea, vomiting, abdominal pain; muscle pain, joint stiffness, and less commonly cardiac or hepatic toxicity; rarely anaphylaxis.

C/I: significant renal impairment, breast-feeding.

Dosage forms: injection, 33% w/v in 2 and 6-ml ampoules.

Alternative :

Amphotericin B, 0.25 to 1 mg/kg by slow infusion daily or on alternate days, or three times a week for up to 8 weeks depending on the response.

S/E: anorexia, nause and vomiting; febrile reaction, headache, muscle and joint pain; disturbance in renal function; cardio-vascular toxicity, blood dyscariasis, neurological disorders including hearing loss, diplopia, convulsion, peripheral neuropathy, abnormal liver function (discontinue treatment), rash and anaphylactic reaction.

Caution: when given parentrally, toxicity is common and therefore close supervision is necessary; a test dose is required. Monitor renal and hepatic functions closely. Blood counts and plasma electrolyte monitoring is also required.

Dosage forms: Powder for injection, 50mg in vial.

OR

Pentamidine Isethionate, 3 to 4 mg/kg i.m daily or every other day for up to 15 doses.

S/E: reversible nephrotoxicity, acute hypotension, pancrititis, hypoglycemia, cardiac arrhythmias, blood dyscariasis, and sterile abscesses at the injection sites.

Caution: risk of severe hypotension following administration (establish baseline blood pressure and administer with the patient lying down; monitor blood pressure at regular intervals, until treatment concluded); hepatic and renal impairment;

Dosage forms: powder for injection, 200 mg in vial.

NB. The condition called "Post Kalazar Dermal Leishmaniasis" should be treated in the same way as the initial illness of kalazar.

B: Cutaneous LeIshmaniasis (Oriental leishmaniasis, Oriental Sore, Leishmaniasis Tropica)

Cutaneous Leshmaniasis is caused by leishmania tropica, which is transmitted by phlebotomus. Before ulceration occurs, there appears dermal infiltrates consisting of large histiocytes filled with many leishman-donovan (L-D) bodies, while during ulceration an influx of neutrophils occurs. Older lesions develop a tuberculoid infiltrate and at this stage either the organisms are scanty or absent.

Diagnosis is established by:

- The clinical presentation in endemic areas,
- The leishmanin intra-dermal test (Leishman Montenegro-Donovan), and
- The demonstration of the organisms in smears.

Treatment

Sodium stibogluconate, given intramuscularly or intravenously for 10 days.
(For S/E, C/I and, Dosage forms, see page 15)