Leishmaniasis
This presentation is the property of its rightful owner.
Sponsored Links
1 / 69

Leishmaniasis PowerPoint PPT Presentation


  • 299 Views
  • Uploaded on
  • Presentation posted in: General

Leishmaniasis. Different stages of Haemoflagellates. Leishmania life cycle. Promastigote Amasitgote Transformation. Leishmania life cycle. Amastigotes replicate in reticuloendothelial cells (mononuclear cells) including; Monocytes Macrophages in lymph nodes, spleen, and lung;

Download Presentation

Leishmaniasis

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Leishmaniasis

Leishmaniasis


Different stages of haemoflagellates

Different stages of Haemoflagellates


Leishmaniasis

Leishmania life cycle

PromastigoteAmasitgote

Transformation


Leishmania life cycle

Leishmania life cycle

  • Amastigotes replicate in reticuloendothelial cells (mononuclear cells) including;

    • Monocytes

    • Macrophages in lymph nodes, spleen, and lung;

    • Kupffer cells in sinusoids of liver

    • Microglial cells in the central nervous system.

    • Dendriticcells

      Promastigotes reproduce in biting fly (Phlebotomus, Lutzomyia)


Leishmania infects and thrives in macrophages

Leishmania infects and thrives in macrophages

  • Promastigotes attached to CR1 and CR3 receptors on the macrophages

  • The parasite invades its host cell passively by phagocytosis (parasitophorous vacuole)


Leishmaniasis

Leishmania sp.

amastigote stage

  • Ovoid smallintracellular parasites in a bone marrow aspirate. The typical rod shaped kinetoplast is seen besides the nucleus.(Giemsa stain).


Leishmaniasis vectors

Leishmaniasis vectors

  • There are over 600 species of sand flies divided into five genera. More than 30 species are proved vectors.

  • Phlebotomus in the Old-world and Lutzomia in the New world are vectors of human leishmaniasis.


Procyclics and metacyclic promastigotes

Procyclics and Metacyclic Promastigotes

  • Amastigotes are released by digestion, transform into procyclic promastigotes and attach to the midgut epithelium

  • Attached promastigotes divide rapidly

  • Metacyclic (infective) promastigotescease replication, detach and pass forward into the pharynx from where they are regurgitated into the bite site

(detached)

(attached)


Two subgenera of leishmania genus

Two subgenera of Leishmania genus

  • subgenus Leishmania: develops in the sand fly’s midgut and foregut (suprapylorian)

    • Both Old world and New world visceral and cutaneous species

  • subgenus Viannia: develops in the hindgut and midgut (peripylarian).

    • L.braziliensis complex, L.guyanensis complex.


Importance

Importance

  • Leishmaniasis is a parasitic disease transmitted by the bite of sand flies.

  • In at least 88 countries.

  • 350 million people at risk.

  • 12 million people are affected by leishmaniasis.

  • 1.5-2 million new cases of cutaneous leishmaniasis estimated to occur annually.

  • 500 000 new cases of VL which occur annually.

  • 90% of CL cases were from Afghanistan, Algeria, Brazil, Iran, Peru, Saudi Arabia and Syria.

  • 90% of VL cases were from Bangladesh, India, Nepal, Sudan and Brazil.

  • 90% of mucocutaneous leishmaniasis occurs in Bolivia, Brazil and Peru.


Endemic areas for leishmaniasis

Endemic areas for leishmaniasis


Leishmaniasis

The disease main forms

  • Cutaneous leishmaniasis (CL)

  • 2. Visceral leishmaniasis (VL),(kala-azar) is the most severe form of the disease. Mortality rate 75-95%

  • 3. Mucocutaneous leishmaniasis (MCL),or espundia, disfiguring, destruction of mucous membranes of the nose, mouth and throat cavities. Reconstructive surgery of deformities is an important part of therapy


Cutaneous leishmaniasis

CutaneousLeishmaniasis


Cutaneous leishmaniasis1

Cutaneous Leishmaniasis

Skin ulcers on the exposed parts of the body such as the face, arms and legs.

Old World: L. major, L. tropica, L. aethiopica (DCL)

New World: L. mexicana, L. pifanoi, L. amazonensis, L. venezuelensis, L. granhami,


Cutaneous leishmaniasis2

Cutaneous Leishmaniasis

  • Characterized by one or more papules, nodules and sores on the skin

  • Sore like a volcano with a raised edge and central crater.

  • Two figures including urban (dry) and rural (wet) forms.

  • Sores are usually painless but can become painful if secondarily infected

  • chronic but self-limiting


Leishmaniasis

  • Infection remains restricted to the initial site of infection (the bite site)


Leishmania tropica

Leishmania tropica

  • Anthroponotic Cutaneous Leishmaniasis (ACL)

  • Definitive Host: Humans

    • (occasionally dog?)

  • Intermediate Host: Phlebotomus sand flies

    • Main vector and also in Iran: P. Sergenti

  • Dry or urban C.L.

  • Face> hand, leg and…

  • Incubation period: 2-8 months(usually 2-3 months)

  • Lesion persist for several months (more than one year) then person is immune


  • Leishmania tropica1

    Leishmania tropica

    • Sores don’t heal very quickly

      • Often mistaken for leprosy or tuberculosis

    • First sign: small papule nodule dry sore

    • Itching

    • Scar (if not treated)


    Leishmaniasis

    • Rarely can cause visceral (viscerotropic) and diffuse cutaneous infections.


    Leishmania major

    Leishmania major

    • Wet or rural form

    • Definitive Host: rodents (Rodentia: Gerbillidae) as reservoir host, Humans

    • In Iran: Rhombomysopimus, Merioneslibycus, M.hurrianae, Tateraindica

    • Zoonotic Cutaneous leishmaniasis (ZCL)

    • Intermediate Host:Phlebotomus sand flies.

      In Iran: P. papatasi.

    • Incubation period: some weeks to 3 months ( usually 2 weeks)

    • First sign: small papule nodule Wet sore (exudates)

    • Itching

    • Scar (if not treated)

    • Disease period is usually short (2-8 months)

    • More in hands and feet


    Leishmaniasis

    Sporotrichoid form

    Diffuse cutaneous leishmaniasis

    Recidivans leishmaniasis


    Leprosy

    Leprosy

    • It is primarily a granulomatous disease of the peripheral nerves and mucosa of the upper respiratory tract.

    • Skin lesions are the primary external sign.

    • Left untreated, leprosy can be progressive, causing permanent damage to the skin, nerves, limbs and eyes.


    Lupus volgaris a sort of cutaneus tb

    Lupus volgaris (a sort of cutaneus TB)

    • Persistent and progressive form of cutaneous TB.

    • Small sharply defined reddish-brown lesions with a gelatinous consistency (called apple-jelly nodules).

    • Lesions persist for years, leading to disfigurement and sometimes skin cancer


    New world cutaneous leishmaniasis

    New World cutaneous leishmaniasis

    • L. mexicana (Chicleros Ulcer)

      • External ear

    • L. pifanoi

    • L. amazonensis

      • main cause of DCL

      • All four leishmaniasis forms

    • L. (V.) peruviana(Uta)

    • L. granhami

    • L. venezuelensis


    Visceral leishmaniasis

    Visceral Leishmaniasis


    Leishmaniasis

    • Systemic infection of reticulo-entdothelial cells (mostly macrophages) throughout multiple internal organs and the blood


    Kala azar visceral leishmaniasis

    Kala-azar , Visceral Leishmaniasis

    • L. donovanicomplex

      • L. donovani(Asia, East Africa)

        • Strain archibaldi

      • L. infantum (Medditeranian basin and Middle East, in children)

      • L. chagasi( South & Central America)

    • L. tropica (viscerotropic)

    • L. amazonensis

    • Weeks to months (2-6 months) incubation period


    Leishmaniasis

    L. donovani, anthroponotic

    L. infantum, zoonosis,

    L. donovani ,(archibaldi), zoonosis,

    L. chagasi, zoonotic


    The most sever leishmaniasis form

    The most sever leishmaniasis form

    • Mortality of untreated disease 75-95%

    • Prolonged fever (usually dromedary but also continuous, reminant, interminnent)

    • Splenomegaly, hepatomeglay,

    • Weight loss (cachexia),

    • Progressive anemia, pancytopenia,

    • Hypergammaglobulinemia and hypoalbominemia

    • Skin darkness ( around mounth, forehead, temple)

    • Lymphadenopathy may be present

    • Elevated liver enzymes, Nausea, vomiting.

    • Pancytopenia: normochrome & normocytic anemia, trombocytopenia, but lymphocytosis


    Visceral leishmaniasis1

    Visceral Leishmaniasis

    • Visceral leishmaniasis should be considered in every case with chronic fever returning from an endemic area.

    • Malaria, tropical splenomegaly, schistosomiasis, cirrhosis, portal hypertension, trypanosomiasis, milliary tuberculosis, brucellosis, typhoid fever, bacterial endocarditis, histoplasmosis, malnutrition, lymphoma, and leukemia (Singh, 2006).

    • Apart from fly biting, other routes including; Placental, blood transfusion, mechanical, sexual routes.


    Viscerotropic leishmaniasis

    Viscerotropic leishmaniasis

    • L. tropica

    • Oligoparasitic leishmaniasis

    • Fever, fatigue, digestive tract problems

    • First in desert storm operation in Iraq among American soldiers

    • In Iran: One case from AIDS patient (Tehran), other case (Shiraz)


    Epidemiology of visceral leishmaniasis in iran

    Epidemiology of visceral leishmaniasis in Iran

    Mediterranean Kala-azar:

    - Causative agent is L. infantum

    - Reservior host: involving canine such as Dog, Jackal, fox, wolf and other wild carnivorouses.

    - The probable main vector in Iran is Phlebotomus major (Fars), other vectors are P.keshishiani (Fars), P. Perfiliewi (Dashte-Moghan),P. kandelakii (Meshkinshahr).

    - Age distribution: the disease mainly occurs in children from 1 to 4 years of age.


    Immunity

    Immunity

    • TH1:

      • Macrophage produces IL12

      • IL12 promote TH0 to TH1

      • TH1 produces INF gama, IL2, TNF

      • Healing and resistance to disease

    • TH2:

      • TH2 produces IL4, IL5, IL6, IL10, IL13

      • Sensitivity to disease


    Diagnosis

    Diagnosis


    Leishmaniasis

    • 1. Clinical Diagnosis:

      • Patient history ( endemic region or travel),

      • Signs & symptoms

        • Sores that will not heal, have to be referred for evaluation.

        • Individuals with fevers, weight loss, gastrointestinal complaints, anemia, hypergammaglobulinemia, abnormal liver tests should be referred for evaluation


    Leishmaniasis

    Laboratory Diagnosis of leishmaniasis :

    1. Cutaneous Leishmaniasis

    • Tissue sample (scraping, aspirate or punch biopsy) for smear and culture

  • Take scrapings from the sore, put on slides, stain with Wright’s or Giemsa’s stains, and look for amastigotes.

  • Culture (NNN & LIT, Evans, RPMI 1640),

  • Laboratory animals inoculation (SouriandBalb/c mouse) only for L. major (no growth in L. tropica)


  • Cutaneous leishmaniasis con

    Cutaneous Leishmaniasis (con.)

    • Leishmania skin test (Montenegro test)

      • 0.1 ml (1,000,000 killed L. majorpromastigote), intradermal,

      • 5mm< induration after 48-72h, DTH

    • Isoenzymeprofiles - Zymodemes

    • No serological approaches usually but monoclonal antibodies can be used.

    • DNA hybridisation - PCR


    Leishmaniasis

    2. Visceral Leishmaniasis

    • Finding Leishmaniaon biopsy of bone marrow (iliac, sternum, tibia (54-86% sensitivity)), liver (60%), enlarged lymph node (64%), or spleen (98%).

    • Culture (NNN, Evans, LIT)

    • Laboratory animals IP inoculation (Golden hamester)

    • No LST for VL and PKDL diagnosis (Yes for VL and CL epidemiology and MCL and Lupoid diagnosis)


    Visceral leishmaniasis con

    Visceral Leishmaniasis (con.)

    • Serologic tests:

      • Antibody detection: DAT (sen 91-100%, spe 72-95%) IFA (sen 55-70, spe 70-89) ELISA,( sen 80-100% spe 84-95) Dipstick test (rk39, recombinant antigen 39kd, sen 67-100% spe 88-100%)

        • DAT is easy, inexpensive, and with high specificity and sensitivity (most usage in Iran)

      • Antigen detection: KAtex (5-20 kd glycoprotein, membranous antigen, easy, field applicable, sen 68-100%, spe 100%, positive only in acute disease, useful for HIV/VL )

    • Formel gel, (Based on hyperimmunoglobulinemia)

      • Multiple myeloma, Schistosomiasis

    • Isoenzyme profiles - Zymodemes

    • Monoclonal antibodies

    • DNA hybridisation – PCR (Schizodem)


    Cutaneous and mucocutaneous treatment

    Cutaneous and mucocutaneous treatment

    • Antimony components : Meglumine antimoniate (Glucantime) and Sodium stibogluconate (Pentostam) are drugs of choice.

      • 20 mg/kg/d IV or IM for 20d

    • Pentamidine, Paromomycin are alternative drugs for CL

    • Amphotricine B for antimony resistant MCL

    • Fluconazole may decrease healing time


    Visceral leishmaniasis treatment

    Visceral leishmaniasis treatment

    • Pentostam or Glucantime 20 mg /kg/d IV or IM for 28d

    • Amphotricin B: 0.5-1 mg/kg IV daily 15-20d

    • Liposomal Amphotricin B (Ambisome): 3 mg/kg/d IV on days 1-5, day 14 and day 21

      • Low toxicity and high stability, better delivery

    • Alternative: Pentamidine(4mg/kg three times weekly, between 5-25 weeks ), Parmomycine


    Visceral leishmaniasis treatment con

    Visceral leishmaniasis treatment (con.)

    • Miltefosine (Impavido) (2.5 mg/kg /d p.o. for 28 d)

      • It was developed for cancer therapy at first

      • The only oral drug

      • safer and more tolerable drug (less toxicity for bone marrow and haematopoietic progenitor cells)

      • teratogenic


    Leishmaniasis control

    Leishmaniasis control

    • Vector control

      • insecticides

      • insecticide impregnated bed nets (IIB)

    • Case finding treatment

    • Aniaml reservoir control

      • Treatment or killing of seropositive dogs

      • Rodent killing

    • Decrease of susceptibility: Childhood age, malnutrition and Immunosuppression are susceptibility factors for VL.

      • eliminating of childhood malnutrition

      • try to produce an efficient vaccine


    Leishmaniasis

    • 0.1 ml in each week for 12 weeks


    Leishmaniasis

    روش نمونه برداری از ضایعات لیشمانیوز پوستی

    • کناره های ملتهب و متورم ضایعات پوستی(لبه خارجی زخم) بیشترین میزان آمستیگوت را دارد.

    • هر چه بافت بیشتر شانس یافتن آمستیگوت بیشتر

    • تمیز کردن محل زخم با پنبه و الکل 70%، با توجه به عفونت باکتریایی و قارچی بر روی ضایعه سالک

    • خشک شدن الکل قبل از نمونه برداری

    • محل نمونه برداری توسط انگشت شصت و سبابه محکم گرفته شود.

    • توسط تیغه اسکالپل نوک باریک و یا لانست استریل شکافی به عمق یک میلی متر در ناحیه ای که توسط دو انگشت گرفته شده ایجاد می شود.

    • از عمق محل شکافته شده خراشهایی به سمت سطح و مرکز ضایعه جهت برداشت نمونه داده می شود.


    Leishmaniasis

    ادامه روش نمونه برداری از ضایعات لیشمانیوز پوستی

    • نوک تیغه اسکالپل را خارج و از مواد برداشت شده 3 اسمیر گرفته می شود و با قلم الماس شماره نمونه یا اسم بیمار بر روی لام شیشه ای ثبت شود.

    • در صورت نیاز به کشت، در کنار شعله نمونه ( بر روی تیغه اسکالپل) به درون محیط کشت دایفازیک منتقل می شود.


    Leishmaniasis

    رنگ آمیزی گیمسا

    • محلول تجارتی غلیظ (و متفاوت)

      • پس از رقیق سازی بتواند گلبول سفید را به خوبی رنگ کند.

    • اسلاید حاوی نمونه بدون شعله ودر دمای اتاق خشک شوند.

    • متانول Methanol 70%

    • متانول خشک شود (اصطلاحا بپرد)

    • بسته به دستور تولید کننده مثلا 1 به 30 یا 1 به 50 رنگ رقیق شود.

      • آبی که جهت رقیق کردن استفاده می شود جهت7.2 pH تنظیم شده باشد.

    • بسته به رقت و نوع آن مدت رنگ آمیزی 20-30 دقیقه است که به طور تجربی بدست می آید.

    • مشاهده با عدسی شیئی 10 و سپس 40 و سپس 100 (با روغن ایمرسیون) ومستقیما بدون لامل

    • حداقل جستجوی 30 شان و یافتن ماکروفاژها در هر کدام از 3 لام

      • نبود ماکروفاژ و فراوانی گلبول قرمز نشانه نمونه نامناسب inadequate)) و ضرورت نمونه گیری مجدد


    Leishmaniasis

    ایزولاسیونکشت در محیط NNN

    • Novy, Macneal, Nicolle

    • آگار 14 گرم

    • NaCl 6 گرم

    • آب مقطر cc 900

    • حرارت (جوشاندن) تا شفاف شدن ( ولی احتیاط جهت سر ریز نشدن)

    • اتو کلاو و سپس سرد شدن تا حرارت 50-60 درجه

    • اضافه کردن گلوکز 30گرم در صد به میزان 5 درصد

    • اضافه کردن خون خرگوش دفیبرینه 10-12 درصد حجم محلول

    • به صورت گرم، تقسیم در لوله های استریل درپیچ دار (3 میلی لیتر)، قرار دادن به شکل slant

    • انتقال به یخچال پس از بستن آگار

    • در هنگام استفاده، اضافه کردن 0.5 تا 1 سی سی PBS یا RPMI به عنوان فاز مایع


    Leishmaniasis

    ادامه کشت

    • نمونه بیوپسی پوستی، آسپیراسیون مغز استخوان و خون

    • 2 میلی متر در عمق پایین ترین سطح شیب دار

    • اینکوباسیون در 22-25 درجه سانتیگراد

    • انگل در فاز مایع رشد کرده و یافت خواهد شد.

    • استریل کار کردن: باکتری و قارچ مانع رشد انگل هستند.

    • بررسی کشت جهت جستجوی انگل: هفته ای یکبار و تا یکماه ( عدم رشد معادل منفی بودن است).

      • اگر انگل دیر رشد باشد زمان بیشتری را نیاز دارد.


  • Login