Jordan University Faculty of Dentistry DR Mohammad Al-Tamimi, MD, PHD

Jordan University
Faculty of Dentistry
Dr Mohammad Al-Tamimi, MD, PhD
Introduction
Two of the many genera of hemoflagellates are
pathogenic to humans, Leishmania and Trypanosoma.
They reside and reproduce within the gut of specific
insect hosts. The life cycle is completed when a second
insect ingests the infected mammalian blood or tissue
fluid
Leishmania species are obligate intracellular parasites
of mammals.
mammals Several strains can infect humans; they
are all morphologically similar
During the course of their passage through insect and
vertebrate hosts, flagellates undergo developmental
change
Species
The many strains can be more simply placed in four
major groups based on their serologic, biochemical,
cultural, and behavioral characteristics
Leishmania tropica and L. mexicana produce a localized
cutaneous lesion or ulcer, known popularly as oriental
sore
L. braziliensis is the cause of American mucocutaneous
leishmaniasis
L. donovani is the etiologic agent of kala azar
Morphology
Promasitogte
Amastigote
Stages in the life cycle of the hemoflagellates
Epidemiology
Endemic in 88 countries
Population at risk: 350 millions
It is estimated that over 20 million people worldwide
suffer from leishmaniasis and 1 to 2 million additional
individuals acquire the infection annually.
More than 90% of C.L. cases occur in; Iran, Algeria
Afghanistan,, Brazil, Peru, Saudi Arabia and Syria
More than 90% of V.L. Cases occur in 5 countries ;
Bangladesh, India , Nepal, Sudan, and Brazil
Annual death due to V.L. is 59,000 cases
Transmission
All four groups are transmitted by phlebotomine
sandflies.
These small, delicate, short-lived insects are found in
animal burrows and crevices throughout the tropics
and subtropics
At night, they feed on a wide range of mammalian
hosts.
Life Cycle
Amastigotes ingested in the course of a meal assume the
flagellated promastigote form, multiply within the gut,
and eventually migrate to the buccal cavity of sandfly
When the fly next feeds on a human or animal host, the
buccal promastigotes are injected into the skin of the
new host together with salivary peptides capable of
inactivating host macrophages
Amastogotes invade macrophage and divides
until the infected cell ruptures
The sandfly acquires the organisms during the blood
meal
Pathogenesis
After the host is bitten by an infected sandfly, the
parasites disseminate in the bloodstream and are taken
up by the macrophages of the spleen, liver, bone
marrow, lymph nodes, skin, and small intestine
Histiocytic proliferation in these organs produces
enlargement with atrophy or replacement of the
normal tissue
Disseminated Intravascular Leishmeniasis (Kala azar)
Kala azar, which is caused by L. donovani, occurs in the
tropical and subtropical areas of every continent except
Australia
In Africa, rodents serve as the primary reservoir. Human cases
occur sporadically, and the disease is often acute and highly
lethal. In Eurasia and Latin America, the domestic dog is the
most common reservoir
Human disease is endemic, primarily involves children, and
runs a subacute to chronic course
In India, the human is the only known reservoir, and
transmission is carried out by sandflies. The disease recurs in
epidemic form at 20year intervals, when a new nonimmune
children and young adults appears in the community
There appears to be a high incidence of visceral leishmaniasis
in patients with HIV infection
Manifestations
The majority of infections are asymptomatic
Symptomatic disease most commonly manifests itself
3 to 12 months after acquisition of the parasite. It is
often mild and self-limited
A minority of infected individuals develop the classic
manifestations of kala azar
1. Fever, which is usually present, may be abrupt or
gradual in onset. It persists for 2 to 8 weeks and then
disappears, only to reappear at irregular intervals
during the course of the disease. A double-quotidian
pattern (two fever spikes in a single day) is a
characteristic but uncommon finding
2. Diarrhea and malabsorption are frequent in Indian cases,
resulting in progressive weight loss and weakness
3. Physical findings include enlarged lymph nodes and liver,
massively enlarged spleen, and edema.
4. In light-skinned individuals, a grayish pigmentation of the
face and hands is commonly seen, which gives the disease
its name (kala azar, black disease)
5. Anemia are typical in advanced cases. Thrombocytopenia
induces petechial formation and mucosal bleeding. The
peripheral leukocyte count is usually low; agranulocytosis
with secondary bacterial infections contributes to lethality.
6. Serum immunoglobulin G levels are enorCirculating
antigen-antibody complexes are present and are probably
responsible for the glomerulonephritis seen so often in this
diseasemously
disease elevated but play no protective role.
Cutaneous Leishmaniasis
Leishmania tropica: Anthroponotic cutaneous
leishmaniasis: Dry lesions with minimal ulceration
Leishmania major: Zoonotic cutaneous leishmaniasis:
wet lesions with severe reaction
Oriental sore (most common) classical self-limited
ulcer
Leishmania tropica
Leishmania major
Oriental sore
Diagnosis
The diagnosis is made by demonstrating the presence
of the organism in aspirates taken from the bone
marrow, liver, spleen, or lymph nodes
The specimens may be smeared, stained, and
examined for the typical Leishman-Donovan bodies
(amastigotes in mononuclear phagocytes) or cultured
in artificial media and/ or experimental animals
A rapid, direct, species-specific diagnosis by PCR and
probes to kinetoplast DNA is used
Results of the leishmanin skin test are negative during
active disease but become positive after successful
therapy
Treatment
The mortality in untreated cases of kala azar is 75 to
90%
Treatment with pentavalent antimonial drugs lower
this rate dramatically. Initial therapy, however, fails in
up to 30% of African cases, and 15% of those that do
respond eventually relapse
Control measures are directed at the Phlebotomus
vector, with the use of residual insecticides, and at the
elimination of mammalian reservoirs by treating
human cases and destroying infective dogs

Jordan University Faculty of Dentistry DR Mohammad Al-Tamimi, MD, PHD

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