Cutaneous leishmaniasis is an urban form of the pathogen. Leishmaniasis: causes, symptoms, diagnosis, treatment and prevention

Etiology. Life cycle.

Visceral leishmaniasis . Pathogenesis.Clinical features. Complications. Diagnostics.Cutaneous leishmaniasis . Pathogenesis.Clinical features.Complications. Diagnostics.Epidemiology and prevention

Additional questions: What clinical signs make one suspect visceral leishmaniasis (cutaneous leishmaniasis) in a patient? What details of the medical history indicate the possibility of leishmaniasis in this patient?

Leishmaniasis– protozoal invasions, the causative agent of which is leishmania. L Eishmaniasis is widespread in countries with tropical and subtropical climates on all continents where mosquitoes live. These are typical natural focal diseases. Natural reservoirs are rodents, wild and domestic predators. Human infection occurs through the bite of infested mosquitoes.

According to the World Health Organization and the Center for Disease Control in 2004, 1/10 of the world's population is at risk of infection with leishmania. Only isolated imported cases are registered in the Russian Federation.

According to the pathogenic effect of leishmania, the diseases they cause are divided into three main forms: skin;mucocutaneous; visceral.

Human diseases are caused by several species and subspecies of parasites, which are combined into 4 complexes:

L. donovani - causative agent of visceral leishmaniasis;

L. tropica - causative agent of cutaneous leishmaniasis;

L. brasiliensis - causative agent of Brazilian leishmaniasis

L. Mexicana - causative agent of leishmaniasis in Central America.

Leishmaniadonovani amazes internal organs, that's why the disease is called visceral(internal) leishmaniasis.

Leishmania tropica - Causes cutaneous leishmaniasis (Borovsky's disease) in humans.

There are two forms of cutaneous leishmaniasis - anthroponotic (cityskuyu) And zoonotic (desert).

Leismania brasiliensis found in South America, and causes mucocutaneous (American) Leishmaniasis. There are many geographical forms of this disease. There are two main geographical forms: visceral leishmaniasis Mediterraneanth type found in the Russian Federation, and Indian kala-azar.

Morphology. All species are morphologically similar and have the same development cycles. Leishmania goes through two stages in its development:

In flagellate, or leishmanial (amostigote); - in flagellate, or promastigote.

Leishmanial the form is very small - 3-5 microns in diameter. Its characteristic feature is a round nucleus, occupying about 1/4 of the cytoplasm; There is no flagellum; a rod-shaped kinetoplast is located perpendicular to the cell surface. These forms live intracellularly (in the cells of the reticuloendothelial system) in macrophages, cells of the bone marrow, spleen, liver of humans and a number of mammals (rodents, dogs, foxes). One affected cell may contain several dozen Leishmania. They reproduce by simple division.

The flagellated form, sown on a nutrient medium, turns into a flagellated one. When stained by Romanowsky, the cytoplasm is blue or bluish-lilac, the nucleus is red-violet, the kinetoplast is stained more intensely than the nucleus (Fig. I).

When a person is bitten by an infected mosquito, mobile forms of Leishmania from his throat penetrate into the wound and then penetrate into the cells of the skin or internal organs, depending on the type of Leishmania. Here they transform into flagellate forms.

Sources of infection in leishmaniasis. The possible role of dogs as a source of infection in visceral leishmaniasis of the Mediterranean type was first pointed out by the French scientist C. Nicole, and this was confirmed by Soviet scientists N.II. Khodukin and M.S. Sofiev. In addition to dogs, some wild animals (jackals, porcupines) can also be the source of the disease. In Indian leishmaniasis (kala-azar), the source of infection is sick people.

A dog affected by leishmaniasis (Fig. 2) develops exhaustion, ulcers on the head and skin of the body, and peeling of the skin, especially around the eyes. It is important to take into account that while in young dogs the disease can be acute and even lead to death, in adult animals the course of the disease is often more subtle or even asymptomatic (carriage).

Visceral leishmaniasis occurs sporadically in Central Asia, southern Kazakhstan, Kyrgyzstan and Transcaucasia.

In cutaneous leishmaniasis, the source of infection is sick people or wild rodents. The main keepers of Leishmania are the great gerbil and the red-tailed gerbil.

Cutaneous leishmaniasis occurs in many oases in the southern part of Turkmenistan and Uzbekistan. In some places, the transmission of this type of leishmaniasis is so intense that local residents manage to get sick from it even in preschool age.

Visceral leishmaniasis(children's, kala-azar, kara-azar) – pathogen - L . donovani . Visceral leishmaniasis most often affects children. After the incubation period, the patient’s temperature rises, reaching 39-40°C at the height of the disease, lethargy and anemia appear , pallor, loss of appetite. Incubation period- from 10 days to 3 years, usually 2-4 months. Symptoms- slowly developing fever and general malaise. Progressive debilitation of an anemic patient. Other classic symptoms are protrusion of the abdomen due to an enlarged liver and spleen. Without treatment - death in 2-3 years.

A more acute form - 6-12 months. Clinical symptoms - edema of the lungs, face, bleeding of the mucous membranes, difficulty breathing, diarrhea.

Features of the course of visceral leishmaniasis depend on the age of the patient. In sick children under 1 year of age, the disease is characterized by a short incubation period and an acute course. For older children and adults, the disease is characterized by a chronic course. The clinical course also largely depends on the intensity of the invasion of the macroorganism and on the duration of the disease.

If left untreated, it usually ends in death, the immediate cause of which is often complications such as pneumonia, dyspepsia, purulent infection, etc.

Mucocutaneous leishmaniasis– pathogens L . braziliensis , L . Mexicana , widespread in South American countries.

The primary lesion is the bite site. Secondary - damage to the mucous membranes of the nose and pharynx. The result is severe disfiguring damage to the lips, nose, and vocal cords. Death is due to secondary infection.

Diagnosis is difficult and requires culturing of affected tissues for accurate diagnosis. Treatment is long-term (several years), dormant stages persist in the mucous membranes.

L . Mexicana - causes cutaneous forms, sometimes in mucous membranes. More often - spontaneous recovery after a few months, with the exception of strange ear lesions. In the latter case, there is severe disfigurement and the course of the disease lasts up to 40 years.

Cutaneous leishmaniasis(Borovsky's disease, eastern ulcer, Pendinsky ulcer) - L . tropica , L . major . They have similar life cycles and similar symptoms of the disease, but different distribution.

Complex L . major - North America, Middle East, Western India, Sudan.

Complex L . tropica - Ethiopia, India, European Mediterranean region, Middle East, Kenya, North. Africa.

Cutaneous leishmaniasis occurs as anthroponotic and zoonotic type.

Anthroponotic type(late ulcerating cutaneous leishmaniasis of urban type, Ashgabat).

Zoonotic type false leishmaniasis (rural type, Pendinsky ulcer, acute necrotizing cutaneous leishmaniasis)

When a person is infected with the causative agent of cutaneous leishmaniasis, after an incubation period of 1-2 weeks to several months (with the zoonotic type, this period is usually short), small tubercles appear at the sites of mosquito bites. They are brownish-reddish in color, medium density, and usually not painful. The tubercles gradually increase in size and then begin to ulcerate - after 3-6 months with the anthroponotic type and after 1-3 weeks with the zoonotic. Ulcers occur with swelling of the surrounding tissue, inflammation and enlargement lymph nodes.

The process lasts several months (in the anthroponotic form - more than a year), ending with recovery. Scars remain at the site of the ulcers, sometimes disfiguring the patient. After an illness, a strong immunity is formed.

Diagnostics. The main symptoms of the anamnesis are the reference when making a clinical diagnosis. Epidemiological data should be taken into account (residence in places unfavorable for leishmaniasis, etc.).

The final and reliable diagnosis of visceral leishmaniasis is made based on the detection of the pathogen. To do this, bone marrow smears stained according to Romanovsky are examined microscopically under immersion. Material for research is obtained by puncture of the sternum (with a special Arinkin-Kassirsky needle) or the iliac crest.

In preparations, Leishmania can be present in groups or singly, intracellularly or freely due to the destruction of cells during the preparation of smears.

For cutaneous leishmaniasis, smears from undissolved tubercles or from the infiltrate nearby are examined. In some cases, the method of culture of the patient's blood (or material from skin lesions or bone marrow) is used. In a positive case, flagellated forms of Leishmania appear in the culture on days 2-10.

Prevention of leishmaniasis. Preventive measures are selected based on the type of leishmaniasis. For visceral leishmaniasis, door-to-door visits are carried out for early identification of patients. They destroy natural reservoirs (rodents, foxes, jackals, etc.), organize the systematic destruction of stray and stray dogs, as well as inspect valuable dogs (chain hunting dogs, guard dogs, etc.). With urban cutaneous leishmaniasis, the main thing is to identify and treat sick people. In the zoonotic type, wild rodents are exterminated. A reliable means of individual prevention is vaccination of a live culture of flagellated forms. A special section of the fight against all types of Leishmania is the destruction of mosquitoes and the protection of people from their bites. In order to protect against attacks by bloodsuckers, indoor netting and pologization are used.

In this article we will look at such a rare disease as leishmaniasis. You will learn which microorganism is the causative agent of the disease, how and where you can become infected with leishmaniasis, and learn to identify the symptoms. We will tell you how leishmaniasis is treated today, what medications are most effective, and what to do to never encounter such a disease. We also list the most popular means traditional medicine that will help in the fight against the disease. As a result, you will be able to take the necessary measures to avoid infection, as well as recognize threatening symptoms in the early stages and consult a doctor in time.

Definition

Routes of infection

Leishmania is transmitted by mosquitoes, which become infected when they bite a sick animal or person. That is, if a mosquito that has bitten an infected person bites a healthy person, infection will occur.

Carriers of protozoan microorganisms (Leishmania) are called reservoirs. The reservoir can be any vertebrate, for example, animals - canids (foxes, jackals, dogs), rodents (gerbils, gophers).

Infected mosquitoes remain infectious throughout their lives and can transmit the disease to large numbers of people and animals.

Varieties

There are many subspecies of leishmaniasis, depending on the region of distribution. There are three main clinical types:

The first time after infection, leishmaniasis may go unnoticed; the incubation period, when there are no symptoms, lasts from 3 months to 1 year. It is possible to notice only the boil that appears at the site of the insect bite. Further, the disease develops depending on the variety. Let's look at them below.

How to distinguish leishmaniasis from a simple boil and begin treatment correctly? This question will be answered by where you will find information about what a boil and a carbuncle are. You will understand how they differ from each other, as well as how they differ from leishmaniasis.

Visceral leishmaniasis

Symptoms of this type appear 3-5 months after infection.

More often, the disease manifests itself gradually: weakness, general malaise occurs, and appetite disappears. Then a fever develops, the temperature rises to 39 - 40 degrees, the fever may subside and reappear. Lymph nodes enlarge.

But the first sign that appears almost immediately after the bite is a papule covered with scales.

With this type of disease, internal organs are affected - the spleen and liver become enlarged.

Over time, liver damage becomes critical, up to ascites (effusion in the abdominal cavity). The bone marrow is affected.

Children are more often susceptible to this form. Due to the enlargement of internal organs, an enlarged abdomen is characteristic.

The symptoms of this type begin with the primary lesion - leishmanioma.

This is a specific granuloma on the skin, consisting of epithelial cells ( connective tissue), plasma cells (which produce antibodies) and lymphocytes (cells immune system).

Necrosis (death) of tissue is also possible. Here the incubation period is shorter - from 10 to 40 days. The primary lesion begins to grow rapidly, reaching 1.5 cm.

After a few days, an ulcer with a thin crust appears. Then the crust falls off, revealing the pink bottom of the ulcer.

First, serous fluid is present in the ulcer, then pus appears. After a couple of days, the bottom of the ulcer dries out, the pus disappears, and scarring occurs.

Cutaneous granuloma is an inflammation of the skin that can be confused with leishmaniasis.

The skin type of the disease is divided into several subtypes:

1. Sequential form. Near the primary granuloma, many small lesions appear that go through the stages described above.
2. Tuberculoid form. Around the scar of the primary lesion and even on the scar itself, tubercles appear, which increase and merge with each other. Sometimes the bumps open up and turn into ulcers.
3. Diffuse-infiltrative form. It is characterized by thickening of the skin and infiltrates (accumulation of cells mixed with blood and lymph). A significant portion of the skin may be affected. Over time, the infiltrate resolves on its own. With this type of ulcer, ulcers appear extremely rarely.
4. Diffuse form. In this form, the disease occurs in people with reduced immunity, for example, HIV-positive people. Characterized by extensive spread of ulcers throughout the body, and this process is chronic.

Leishmaniasis of the mucous membranes

This form also occurs in the presence of primary specific skin granulomas. First, extensive ulcers appear on the body, often on the arms and legs.

Then the mucous membranes of the nose, cheeks, larynx, and pharynx are affected. Necrosis (tissue dies) and ulcers appear there. Defeats destroy cartilage tissue, so facial deformation is possible.

An infectious diseases specialist will tell you more about the routes of infection with leishmaniasis and the types of the disease:

When diagnosing leishmaniasis, a thorough interview is first carried out and an anamnesis is collected. It is determined whether the person has been to epidemiologically dangerous areas for leishmaniasis. Then the following diagnostic procedures are carried out:

• For cutaneous or mucocutaneous leishmaniasis, smears are taken from tubercles or ulcers. Then the samples are sent for bacteriological examination.
• Microscopic studies are being carried out. First, material is collected for skin lesions from ulcers; for the visceral type, a puncture (puncture with material collection) of the bone marrow, lymph nodes, and spleen is performed. Next, the samples are stained according to Romanovsky-Giemsa. Leishmania are the simplest microorganisms; with this staining, they acquire a blue color, and the nuclei become red-violet.
• Conduct serological studies blood. To do this, blood is taken from a vein and the content of antibodies to leishmaniasis is analyzed. If the antibody titer is high, this confirms the presence of the disease. Antibodies are absent in people with immune system diseases (AIDS).

Treatment

Treatment is prescribed based on the type and prevalence of the disease. For visceral and mucocutaneous diseases, systemic therapy is used. For cutaneous leishmaniasis with a small area of ​​lesions, local treatment (with ointments) is possible.

Treatment of visceral type

Traditional therapy is carried out medicines based on antimony. The following medications are prescribed:

• • — active substance sodium stibogluconate or a compound of pentavalent antimony and gluconic acid. Analogue of “Solyusurmin”.

• • “Glucantim”- the active substance pentacarinate is a specific antiprotozoal agent, that is, a medicine that gets rid of protozoa.

• • prescribed for resistance (resistance) to the drugs listed above. It is an antifungal agent that is clinically effective against leishmaniasis.

The patient is prescribed bed rest. For additional bacterial infections, antibiotics are used.

Enhanced nutrition is required. Additional symptomatic therapy is possible.

For example, for liver damage, hepatoprotectors are given (Heptral, Essentiale). In difficult cases it is carried out surgical intervention- splenectomy (removal of the spleen).

Treatment of cutaneous leishmaniasis

For minor skin lesions, you can get by with local treatment of the ulcer:

• Sodium stibogluconate is injected directly intradermally into the area of ​​leishmanioma.
• Thermal therapy or cryodestruction is used - freezing an area of ​​skin with liquid nitrogen, followed by death of the affected tissue.

For extensive lesions, therapy is identical to the treatment of the visceral form. Also, for small skin lesions, antifungal agents are effective - long-term antifungal systemic drugs (up to 8 weeks) - Fluconazole, Itraconazole.

Treatment of the mucocutaneous form

Here, the systemic therapy described above is used, but the treatment is much more complicated, due to the fact that all mucous membranes are affected and even the face is distorted due to the destruction of cartilage tissue.

Folk remedies

Traditional medicine is powerless against leishmania, but in the cutaneous form there is effective recipes, which in combination with drug therapy promote the healing of ulcers and leishmaniomas.

Cocklebur decoction

How to cook: Pour 10 grams of dry cocklebur grass into a glass of water. Bring to a boil, simmer over low heat for 3 minutes. Then let it sit for an hour.

How to use: Wipe the affected areas with the decoction twice a day for a month. Cocklebur herb perfectly relieves secondary bacterial and fungal infections and relieves inflammation. The decoction is especially effective for purulent ulcers.

Ingredients:

1. Dried elecampane root 50 gr.
2. Vaseline 200 gr.

How to cook: Grind the elecampane root and mix with Vaseline until smooth.

How to use: lubricate the affected areas, ulcers and tubercles with the resulting composition at night. The ointment is used over a long course of up to several months. Elecampane root contains natural resins, wax, essential oils, vitamin E, inulin polysaccharide. This composition copes well with various types of inflammation and accelerates healing.

In a broad sense, the prevention of leishmaniasis consists of measures to combat animal carriers and insect vectors. To do this, in dangerous areas, vacant lots and landfills are eliminated, basements are drained, rodents are removed, and insecticidal treatment is carried out. The population is recommended to use repellents (substances that repel insects, in particular mosquitoes).

In special cases, to prevent infection with leishmaniasis, for example, tourists going to an area where the disease is widespread, vaccination is recommended. There is a live L. major strain vaccine that is effective in preventing infection.

Question answer

Can you get leishmaniasis from a sick person? How to protect yourself if you have to be among people with leishmaniasis?

It is impossible to become infected with leishmaniasis directly from a reservoir (human, animal). In the body of vertebrates, Leishmania is in an immature flagellated form and cannot be transmitted by household, airborne or other means.

Leishmaniasis is transmitted through the bite of an infected mosquito; in the throat of the insect, leishmania becomes active and enters the human or animal body through the wound from the bite.

I am about to go on a business trip to Africa, they warned me that leishmaniasis is raging there. How to stay safe?

A vaccine containing a live strain of Leishmania will help prevent infection with leishmaniasis.

Recently we were on vacation in Mexico and I was bitten by a mosquito. Now there is a strange lump in this place, is this a standard reaction, or should I see a doctor?

Mexico is one of the regions where leishmaniasis is common. Contact an infectious disease specialist as soon as possible and submit a smear or tissue scraping for bacteriological and microscopic examination.

Is it possible to avoid skin leishmaniasis? local treatment and not poison the body with toxic injections?

For isolated skin ulcers caused by leishmaniasis, topical treatment can be used. To do this, antimony preparations (“Pentostam”, “Solyusurmin”) are injected intradermally. You can also resort to cryodestruction and excise the formation.

A friend contracted leishmaniasis in Africa. She has a visceral form. Doctors suggest removing the spleen, will this help cure?

Splenectomy is the removal of the spleen, performed in advanced cases. Since the visceral form is characterized by damage to internal organs and the spleen primarily. However, this does not replace systemic drug therapy and is not a panacea.

What to remember:

1. Leishmaniasis is caused by protozoan microorganisms called Leishmania.
2. Infection occurs through a mosquito bite.
3. Infection from a sick person or animal is impossible.
4. Leishmaniasis comes in three forms: visceral (with damage to internal organs), cutaneous and mucocutaneous.
5. Diagnosis of leishmaniasis is carried out using microscopic examination of material (exudate from ulcers, bone marrow smears, etc.), the visceral type can be determined using serological tests of venous blood for the presence of antibodies to leishmaniasis.
6. Pentavalent antimony preparations are used for treatment; if the disease is not advanced, the prognosis is favorable.
7. Single lesions of cutaneous leishmaniasis are treated locally with intradermal injections.
8. Infection can be prevented using a specialized live vaccine.

1) (anthropotic form) is a disease characterized by the slow formation of ulcers on the face, legs and arms. At the site of pathogen penetration, a small tubercle forms, slowly enlarging and after 3-6 months becoming covered with a scaly crust, under which an ulcer is found. Scarring occurs slowly and ends after 1-2 years. Despite the relative “harmlessness” of this form, up to 200 scars subsequently remain on the human body, which disfigures the face, body and overall appearance, due to which patients are discriminated against in society ( Photo 1). (The article uses photographs from WHO materials-approx. author).

The “brother” of the anthroponotic form is the zoonotic form of cutaneous leishmaniasis, which was described by the Russian doctor Borovsky at the end of the 19th century, by whose name it is known to many clinicians as Borovsky’s disease.

It is characterized by a shorter incubation period - within a few weeks, the tubercle at the bite site grows up to 10-15 mm, with rapid tissue necrosis in the center and the formation of an open ulcer with a wide infiltrate and swelling around, sometimes up to several centimeters in diameter. The ulcer heals within several months.( Photo 2).

Although cutaneous forms of leishmaniasis, with some exceptions, can be treated with pentavalent antimony drugs (solusurmin), sometimes with antifungal drugs(successful use of fluconazole for the treatment of certain forms of cutaneous leishmaniasis in India has been described), they represent serious problem, since about 1.5 million new cases of the disease are registered annually in the world .

2) - a kind of “chameleon disease”. Besides that clinical picture the disease is strikingly reminiscent of the lepromatous form of leprosy ( Photo3), and sometimes the skin test for leishmaniasis is negative!

All additional clinical and laboratory methods- with leishmaniasis, there are a number of symptoms common to cutaneous and mucocutaneous forms: anemia, leukopenia (decreased number of leukocytes in the blood), agranulocytosis, thrombocytopenia (decreased number of platelets in the blood), increased ESR, decreased albumin content and increased globulin levels.

Even when a diagnosis is made, treatment poses enormous difficulties - this form progresses rapidly and is difficult to treat with both solusurmin and extremely toxic polyene antibiotics (amphotericin B), which have proven themselves as a treatment for leishmaniasis.

3)Mucocutaneous leishmaniasis (espundia) - also a “chameleon disease”, which is very difficult to differentiate from leprosy, syphilis or nasopharyngeal cancer (given that it is characterized by late metastatic lesions) (Photo 4).

This is a form of the disease that affects both the skin and mucous membranes, destroying the mucosal membranes of the throat, nose, and adjacent soft tissues, leading to the formation of painful, disfiguring ulcerations. Patients often die as a result of bacterial infection, exhaustion, aspiration pneumonia and obstruction respiratory tract. In addition, isolating Leishmania from tissues presents significant difficulties - very often they are not detected at all. Their growth in nutrient media is also slow - often the diagnosis becomes clear only at 4-6 weeks of the course of the disease, only by blood culture methods.

The prognosis depends on the specific type of pathogen; patients are treated with solyusurmin and polyene antibiotics (). This form of leishmaniasis is associated with the most pronounced deformities. Patients, as a rule, remain with a disfigured appearance, and entry into society, according to the traditions of their countries of residence, is closed to them.

4) Visceral leishmaniasis (kala-azar ) - “mansion” standing form leishmaniasis. It is dangerous because without treatment, its mortality rate reaches 100%. The disease mainly affects young children, who become infected with it from dogs, the reservoirs of the infection, but adults are also affected. The incubation period for visceral leishmaniasis lasts an average of 3 months, but can “stretch” from 3 weeks to 3 years.

Visceral leishmaniasis sometimes begins acutely, with a temperature of 39-40C, and is characterized by prolonged fever, enlargement of the liver and spleen, severe leukopenia, anemia, and a progressive course.

But often the disease begins gradually and unnoticed. General weakness increases, fever appears, which is often wavy, increasing anemia and.

Indicative clinical sign there is always a significant enlargement of the liver (to the umbilical line) and spleen (to the pelvic cavity). In approximately 10% of patients, and are noted. ( Photo 5). In the later stages of the disease, swelling, wasting () and hyperpigmentation develop (kala-azar means “black disease”).

Patients without treatment usually die from gastrointestinal bleeding. But even with treatment, a certain percentage of patients develop post-kalaazar dermal leishmaniasis as a “continuation” of the disease, characterized by the presence of a whole spectrum of skin lesions, usually, however, lasting no more than a few weeks.

With the visceral form of leishmaniasis, timely initiation of treatment is very important - in the later stages of the disease, even with intensive treatment, mortality remains at 15-25%, while the cure rate exceeds 90% in cases where therapy is started in a timely manner.

For the treatment of visceral leishmaniasis, the same pentavalent antimony drugs are used, effective against leishmania () in combination with amphotericin B or the aminoglycoside antibiotic paromomycin. A chemotherapy drug that appeared on the pharmaceutical market in the last decade - miltefosine - is quite effective for treating the visceral form.

The main problem in the treatment of leishmaniasis remains the need to unify the diagnostic approach and accurately identify the pathogen (the prognosis of the development of the disease largely depends on this). These two requirements are basic for prescribing appropriate therapy.

Currently, as already mentioned, pentavalent antimony drugs, amphotericin B, and, to a lesser extent, metronidazole, and sitamakin are used to treat leishmaniasis. Oral miltefosine has recently been released, but its high toxicity and equally high cost limit its use.

The main means of combating leishmaniasis, no matter how trite it sounds, remains prevention: early detection and treatment of patients (including those who came to Europe from endemic countries), control of mosquito vectors, and the use of repellents. Vaccination against leishmaniasis plays a huge preventive role: in last years Vaccinations against cutaneous leishmaniasis are successfully carried out with various vaccine compositions.

As for Indian visceral leishmaniasis, WHO even suggests the possibility of its complete eradication in the Indian region. The development of new medical technologies and the research of new drugs allow us to hope that the effectiveness of treatment of leishmaniasis, especially its individual forms, will become greater and greater.

However, not all leishmaniases are strict zoonoses, that is, their natural reservoir is animals. Two types of pathogens have also been identified, which are purely anthroponotic infections (only people suffer from them). This zoonosis is characterized by a fairly narrow distribution area. The incidence is mainly recorded on the African continent and in the countries of South America. This is due to the fact that only limited animal species can be the primary reservoir of the pathogen, and mosquitoes are the carriers. Symptoms and treatment of leishmaniasis in people may vary depending on physiological characteristics body.

Causes

• Presence of pathogen infectious disease, which belongs to the genus of flagellated protozoa Leishmania.
• Presence of natural foci of the pathogen. They are limited by the habitat of animals with this infectious pathology and their carriers, mosquitoes.
• A sick person or animal will be epidemically dangerous for others for quite a long time. This period is limited by the time that leishmania is present in the bloodstream and skin of the patient, that is, virtually during all stages of leishmaniasis.
• The least dangerous in epidemic terms are patients with a visceral course of the infectious process, since in this case leishmania is least accessible to blood-sucking insects.
• Mosquito infection occurs as a result of the bite of a sick animal or person. When the pathogen enters the intestinal tract of an insect, it changes from the amastigote form to the promastigote form. A week after infection, the mosquito becomes infectious to a susceptible animal or person and remains so throughout its life.
• In regions endemic for this infection, cases of human infection during the provision of medical care, for example, as a result of blood transfusion.
• After an illness, immunity is developed, however, it is strictly specific. That is, if infected with another representative of the Leishmania genus, a person may develop a similar infection again.

How does the infection develop?

Classification

There is no generally accepted classification for this infection. However, based on symptomatic manifestations Most authors identify two main clinical trends:

• A cutaneous form, which is characterized by predominantly damage to the outer integument of the patient’s body.
• In the visceral course of the disease, the infectious process covers the internal organs of the patient.

Depending on the main source of infection, epidemiologists distinguish:

• zoonotic pathologies, where the main reservoir will be a sick animal;
• if the source of infection is a person, then they speak of an anthroponotic infection.

Symptoms of leishmaniasis in humans

Depending on the symptoms detected, the clinical course of leishmaniasis infection is divided into visceral and cutaneous forms.

Visceral leishmaniasis is characterized by the following symptoms:

• The incubation period for this form is quite long and can last up to six months.
• It is characterized by a gradual increase in symptomatic manifestations. Acute form is quite rare.
• The first signs are increasing symptoms of acute intoxication with fever. However, short periods of remission are possible.
• When examined during this period, an increase in regional lymph nodes is revealed, which is not accompanied by algia.
• The liver and spleen are significantly enlarged. On palpation they are dense, but painless. The functioning of these organs is also impaired. Therefore, the detection of portal hypertension in leishmaniasis is not uncommon.
• Symptoms of central lesions may be detected nervous system and, in particular, the spinal cord.
• The onset of the terminal stage is characterized by the appearance of areas of dark pigmentation of the skin, cachexia and symptoms of edematous-ascitic syndrome.

The cutaneous form of leishmaniasis has a shorter incubation period, which lasts on average up to three weeks.

There are several clinical forms that have their own symptomatic nuances, but they are all characterized by the presence of primary leishmanioma, which forms at the site of the bite of an insect infected with the pathogen. An ulcer with serous-purulent discharge is formed from the tubercle formed after the bite. It heals in the form of a scar.

Diagnostics

Treatment of leishmaniasis

• The patient must be hospitalized and must remain in bed.
• To prevent the development of the mucous form of inflammation, the oral cavity is thoroughly cleaned.
• The basis of therapy is Miltefosine (Impavido), which is prescribed for almost any form of infection.
• For the visceral form of leishmaniasis, antimony drugs can be prescribed.
• Chemotherapy with glucantime or amphotericin B.
• Antibiotic therapy makes sense only when a secondary infection occurs. The causative agent of leishmaniasis very quickly becomes resistant to this treatment method.
• If necessary, surgery may be performed.

Treatment of leishmaniasis in humans is usually always successful.

Prevention

• Destruction various methods carriers of infectious disease pathogens.
• Local populations living in endemic areas and people visiting these areas are advised to use protective equipment and repellents.
• Patients must be promptly identified and treated.

Forecast

• With timely diagnosis and necessary therapy Almost all patients recover.
• With severe infection and the use of chemotherapy drugs, the mortality rate does not exceed 25%.
• In the absence of adequate therapy, up to 90% of patients die.

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According to the World Health Organization, leishmaniasis occurs in 88 countries of the Old and New Worlds. Of these, 72 are developing countries, and among these, thirteen are the poorest countries in the world. Visceral leishmaniasis occurs in 65 countries.

Leishmaniasis is one of the neglected diseases.

What causes Leishmaniasis

Reservoir and sources of invasion- humans and various animals. Among the latter, the most important are jackals, foxes, dogs and rodents (gerbils - large, red-tailed, midday, thin-toed ground squirrel, etc.). Infectiousness lasts for an indefinitely long time and is equal to the period of residence of the pathogen in the blood and ulceration of the host’s skin. The duration of cutaneous leishmaniasis in gerbils is usually about 3 months, but can reach 7 months or more.

Main epidemiological signs of leishmaniasis. Indian visceral leishmaniasis (kala-azar), caused by L. donovani, is an anthroponosis. Distributed in a number of areas of Pakistan, Bangladesh, Nepal, China, etc. It is distinguished by outbreaks of the disease that occur from time to time. Mostly teenagers and young people, mainly living in rural areas, are affected.

South American visceral leishmaniasis(visceral leishmaniasis of the New World), caused by L. chagasi, is close in its manifestations to Mediterranean-Central Asian leishmaniasis. The incidence is mainly sporadic in a number of countries in Central and South America.

Anthroponotic cutaneous leishmaniasis of the Old World(Borovsky's disease), caused by L. minor, is common in the Mediterranean, the countries of the Near and Middle East, in the western part of the Hindustan Peninsula, Central Asia and Transcaucasia. The disease occurs mainly in cities and towns where mosquitoes live. Among the local population, children are more likely to get sick; among visitors, people of all ages are more likely to get sick. Summer-autumn seasonality is typical, which is associated with the activity of vectors.

Zoonotic cutaneous leishmaniasis of the Old World(Pendin's ulcer) is caused by L. major. The main reservoir of invasion is rodents (great and red gerbils, etc.). Distributed in the countries of the Middle East, North and West Africa, Asia, Turkmenistan and Uzbekistan. Endemic foci are found mainly in deserts and semi-deserts, in rural areas and on the outskirts of cities. The summer seasonality of infections is determined by the period of mosquito activity. Mostly children are affected; outbreaks of diseases among people of different ages are possible among visitors.

Zoonotic cutaneous leishmaniasis of the New World(Mexican, Brazilian and Peruvian cutaneous leishmaniasis), caused by L. mexicana, L. braziliensis, L. peruviana, L. uta, L. amazoniensis, L. pifanoi, L. venezuelensis, L. garnhami, L. panamensis, are registered in Central and South America, as well as in the southern regions of the USA. The natural reservoir of pathogens is rodents, numerous wild and domestic animals. The disease occurs in rural areas, mainly during the rainy season. People of all ages get sick. Usually infection occurs while working in the forest, hunting, etc.

Pathogenesis (what happens?) during Leishmaniasis

When mosquito bites, Leishmania in the form of promastigotes enters the human body. Their primary reproduction in macrophages is accompanied by the transformation of pathogens into amastigotes (flagellate-free form). In this case, productive inflammation develops, and a specific granuloma is formed at the site of penetration. It consists of macrophages containing pathogens, reticular, epithelioid and giant cells. A primary affect is formed in the form of a papule; later, with visceral leishmaniasis, it resolves without a trace or becomes scarred.

With cutaneous leishmaniasis, destruction of the skin develops at the site of the former tubercle, ulceration and then healing of the ulcer with the formation of a scar. Spreading by the lymphogenous route to regional lymph nodes, leishmania provokes the development of lymphangitis and lymphadenitis, the formation of limited skin lesions in the form of successive leishmaniomas. The development of tuberculoid or diffusely infiltrating cutaneous leishmaniasis is largely due to the state of reactivity of the body (hyperergy or hypoergy, respectively).

Along with cutaneous forms of the disease, so-called mucocutaneous forms can be observed with ulceration of the mucous membranes of the nasopharynx, larynx, trachea and subsequent formation of polyps or deep destruction of soft tissues and cartilage. These forms are registered in South American countries.

Convalescents develop persistent homologous immunity.

Symptoms of Leishmaniasis

In accordance with the clinical features, etiology and epidemiology, leishmaniasis is divided into the following types.

Visceral leishmaniasis (kala-azar)
1. Zoonotic: Mediterranean-Central Asian (children's kala-azar), East African (dum-dum fever), mucocutaneous leishmaniasis (New World leishmaniasis, nasopharyngeal leishmaniasis).
2. Anthroponotic (Indian kala-azar).

Cutaneous leishmaniasis
1. Zoonotic (rural type of Borovsky's disease, Pendensky ulcer).
2. Anthroponotic (urban type of Borovsky's disease, Ashgabat ulcer, Baghdad boil).
3. Cutaneous and mucocutaneous leishmaniasis of the New World (espundia, Breda disease).
4. Ethiopian cutaneous leishmaniasis.

Visceral Mediterranean-Asian leishmaniasis.
Incubation period. Varies from 20 days to 3-5 months, in rare cases up to 1 year or more. In children early age and rarely in adults, long before the general manifestations of the disease, a primary affect occurs in the form of a papule.

Initial period of the disease. Characterized by the gradual development of weakness, loss of appetite, adynamia, pallor of the skin, and a slight enlargement of the spleen. Body temperature rises slightly.

High period. It usually begins with a rise in body temperature to 39-40 °C. Fever becomes wavy or irregular and lasts from several days to several months with alternating episodes high temperature and remissions. In some cases, body temperature during the first 2-3 months can be low-grade or even normal.

When examining patients, polylymphadenopathy (peripheral, peribronchial, mesenteric and other lymph nodes), enlargement and hardening of the liver and even to a greater extent of the spleen, painless on palpation, are determined. In cases of development of bronhadenitis, a cough is possible, and pneumonia of a secondary bacterial nature is not uncommon.

As the disease progresses, the condition of patients progressively worsens. Weight loss (even cachexia) and hypersplenism develop. Bone marrow lesions lead to progressive anemia, granulocytopenia and agranulocytosis, sometimes with necrosis of the oral mucosa. Manifestations of hemorrhagic syndrome often occur: hemorrhages in the skin and mucous membranes, bleeding from the nose, and gastrointestinal tract. Fibrous changes in the liver lead to portal hypertension with edema and ascites, which is facilitated by progressive hypoalbuminemia.

Due to hypersplenism and the high position of the diaphragm, the heart shifts somewhat to the right, its sounds become muffled, tachycardia and arterial hypotension develop. These changes, along with anemia and intoxication, lead to the appearance and worsening of signs of heart failure. Possible diarrhea, menstrual irregularities, impotence.

Terminal period. Cachexia, a drop in muscle tone, thinning of the skin, the development of protein-free edema, and severe anemia are observed.

The disease can manifest itself in acute, subacute and chronic forms.
Acute form. Occasionally found in young children. It develops rapidly and without treatment quickly ends in death.
Subacute form. Seen more often. Characterized by severe clinical manifestations, lasting 5-6 months.
Chronic form. It develops most often, often occurring subclinically and latently.

With visceral anthroponotic leishmaniasis (Indian kala-azar), in 10% of patients, several months (up to 1 year) after therapeutic remission, so-called leishmanoids appear on the skin. They are small nodules, papillomas, erythematous spots or areas of skin with reduced pigmentation, which contain Leishmania for a long time (years and decades).

Cutaneous zoonotic leishmaniasis(Pendin's ulcer, Borovsky's disease). Found in tropical and subtropical countries. The incubation period varies from 1 week to 1.5 months, on average 10-20 days. At the site of the entrance gate, primary leishmanioma appears, initially representing a smooth pink papule with a diameter of 2-3 mm. The size of the tubercle quickly increases, and it sometimes resembles a boil, but is painless or slightly painful on palpation. After 1-2 weeks, necrosis begins in the center of the leishmanioma, resembling the head of an abscess, and then a painful ulcer up to 1-1.5 cm in diameter is formed, with undermined edges, a thick rim of infiltrate and abundant serous-purulent or sanguineous exudate; Small secondary tubercles often form around it, the so-called “tubercles of seeding”, which also ulcerate and, when fused, form ulcerative fields. This is how sequential leishmanioma is formed. Leishmaniomas are most often localized on exposed parts of the body, their number varies from a few to dozens. The formation of ulcers in many cases accompanies the development of painless lymphangitis and lymphadenitis. After 2-6 months, epithelization of the ulcers and their scarring begin. The total duration of the disease does not exceed 6-7 months.

Diffuse infiltrating leishmaniasis. It is characterized by pronounced infiltration and thickening of the skin with a large area of ​​distribution. Gradually the infiltrate resolves without a trace. Minor ulcerations are observed only in exceptional cases; they heal with the formation of barely noticeable scars. This variant of cutaneous leishmaniasis is very rare in older people.

Tuberculoid cutaneous leishmaniasis. Sometimes observed in children and young people. It is characterized by the formation of small tubercles around scars or on them. The latter can increase and merge with each other. As the disease progresses, they occasionally ulcerate; subsequently the ulcers heal with scarring.

Cutaneous antroponotic leishmaniasis. It is characterized by a long incubation period of several months or even years and two main features: slow development and less severe skin lesions.

Complications and prognosis
Advanced leishmaniasis can be complicated by pneumonia, purulent-necrotic processes, nephritis, agranulocytosis, and hemorrhagic diathesis. The prognosis of severe and complicated forms of visceral leishmaniasis with untimely treatment is often unfavorable. In mild forms, spontaneous recovery is possible. In cases of cutaneous leishmaniasis, the prognosis for life is favorable, but cosmetic defects are possible.

Diagnosis of Leishmaniasis

Visceral leishmaniasis should be distinguished from malaria, typhoid-paratyphoid diseases, brucellosis, lymphogranulomatosis, leukemia, and sepsis. When establishing a diagnosis, epidemiological history data are used, indicating that the patient has been in endemic foci of the disease. When examining a patient, it is necessary to pay attention to prolonged fever, polylymphadenopathy, anemia, weight loss, hepatolienal syndrome with a significant enlargement of the spleen.

Manifestations of cutaneous zoonotic leishmaniasis are differentiated from similar local changes in leprosy, skin tuberculosis, syphilis, tropical ulcers, and epithelioma. In this case, it is necessary to take into account the phase nature of the formation of leishmanioma (painless papule - necrotic changes - ulcer with undermined edges, a rim of infiltrate and serous-purulent exudate - scar formation).

Laboratory diagnosis of leishmaniasis
The hemogram reveals signs of hypochromic anemia, leukopenia, neutropenia and relative lymphocytosis, aneosinophilia, thrombocytopenia, and a significant increase in ESR. Poikilocytosis, anisocytosis, anisochromia are characteristic, agranulocytosis is possible. Hypergammaglobulinemia is noted.

In cutaneous leishmaniasis, pathogens can be detected in material obtained from tubercles or ulcers; in visceral leishmaniasis, in smears and thick drops of blood stained according to Romanovsky-Giemsa, much more often (95% positive results) - in bone marrow punctate smears. A culture of the pathogen (promastigote) can be obtained by inoculating the punctate on NNN medium. Sometimes a biopsy of the lymph nodes and even the liver and spleen is performed to detect leishmania. Serological reactions are widely used - RSK, ELISA, RNIF, RLA, etc., biological tests on hamsters or white mice. During the period of convalescence, a skin test with leishmanin (Montenegro reaction), used only in epidemiological studies, becomes positive.

Treatment of Leishmaniasis

For visceral leishmaniasis, pentavalent antimony preparations (solyusurmin, neostibosan, glucantim, etc.) are used in the form of daily intravenous infusions in increasing doses starting from 0.05 g/kg. The course of treatment is 7-10 days. If the clinical effectiveness of the drugs is insufficient, amphotericin B is prescribed at 0.25-1 mg/kg slowly intravenously in a 5% glucose solution; The drug is administered every other day for a course of up to 8 weeks. Pathogenetic therapy and prevention of bacterial complications are carried out according to well-known schemes.

In cases of cutaneous leishmaniasis, at the early stage of the disease, the tubercles are injected with solutions of mepacrine, monomycin, hexamine, berberine sulfate; ointments and lotions are used using these products. For formed ulcers, intramuscular injections of monomycin are prescribed at 250 thousand units (for children 4-5 thousand units/kg) 3 times a day, the course dose of the drug is 10 million units. You can treat with aminoquinol (0.2 g 3 times a day, 11-12 g of the drug per course). Laser irradiation of ulcers is used. Pentavalent antimony drugs and amphotericin B are prescribed only in severe cases of the disease.

Drugs of choice: sodium antimonyl gluconate 20 mg/kg IV or IM once a day for 20-30 days; meglumine antimoniate (glucantim) 20-60 mg/kg deep IM once a day for 20-30 days. If the disease relapses or treatment is insufficiently effective, a second course of injections should be administered within 40-60 days. Additional administration of allopurinol 20-30 mg/kg/day in 3 doses orally is effective.

Alternative drugs for relapses of the disease and resistance of the pathogen: amphotericin B 0.5-1.0 mg/kg IV every other day or pentamidine IM 3-4 mg/kg 3 times a week for 5-25 weeks. If chemotherapy has no effect, human recombinant interferon γ is additionally prescribed.

Surgery. Splenectomy is performed according to indications.

Prevention of Leishmaniasis

Control of animal carriers of leishmania is carried out in an organized manner and on a large scale only for zoonotic cutaneous and visceral leishmaniasis. They carry out deratization measures, improvement of populated areas, elimination of vacant lots and landfills, drainage of basements, treatment of residential, household and livestock premises with insecticides. The use of repellents and mechanical means of protection against mosquito bites is recommended.

After identifying and treating sick people, the source of the infection is neutralized. In small groups, chemoprophylaxis is carried out by prescribing chloridine (pyrimethamine) during the epidemic season. Immunoprophylaxis of zoonotic cutaneous leishmaniasis is carried out with a live culture of promastigotes of the virulent strain of L. major during the inter-epidemic period among persons traveling to endemic foci or non-immune individuals living in these foci. 04/05/2019

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