Leishmaniasis

Leishmaniasis - Acute
Rahul Soman, M. Pharm

 

Definition  

A parasitic infection caused by a member of the Leishmania protozoal family comprising both localized cutaneous and disseminated disease affecting the skin, mucosa, or viscera

 

Medical History  

* Travel

* Overseas military service in Middle East

* HIV infection

* Disorder related to transplantation

 

Findings  

* Papular eruption

* Nodule in skin or mucosa

* Skin ulcer

* Skin plaque

* Erythema

* Mucosal ulcer

* Nasal congestion

* Epistaxis

* Hoarse

* Fever

* Weight loss

* Night sweats

* Loss of appetite

* Hepatomegaly - Acute

* Splenomegaly

* Abdominal pain - Acute

* Diarrhea

* Fatigue

* Cough

* Muscle weakness

* Pale complexion

* Symmetrical growth retardation

* Discoloration of skin

* Lymphadenopathy - Acute

 

Tests  

 

Suspected cutaneous, mucocutaneous, or visceral leishmaniasis  

* Microscopy: Cutaneous, mucocutaneous, and visceral leishmaniasis may be diagnosed by microscopic visualization of the parasite .

* Leishmania species culture: Cutaneous, mucocutaneous, and visceral leishmaniasis may be diagnosed if Leishmania is found on culture .

 

Suspected cutaneous, mucocutaneous, or visceral leishmaniasis  

* Polymerase chain reaction analysis: PCR may be used to diagnose cutaneous, mucocutaneous, and visceral leishmaniasis

 

Suspected visceral leishmaniasis  

* Parasite serologic study, Leishmania: A positive leishmaniasis serology test associated with the appropriate clinical presentation is presumptive evidence of visceral leishmaniasis .

 

Suspected cutaneous or mucocutaneous leishmaniasis  

* Parasite serologic study, Leishmania: Serologic tests are often negative in cutaneous leishmaniasis ; the tests often turn positive in mucocutaneous leishmaniasis .

 

Diagnostic work up for visceral leishmaniasis to rule out anemia, leukopenia, and thrombocytopenia  

* Complete blood count

 

Diagnostic work up for visceral leishmaniasis to rule out hypergammaglobulinemia  

* Total immunoglobulin measurement

 

Differential Diagnosis  

* Bacterial infection of skin

* Eczema

* Tinea

* Infestation by fly larvae

* Traumatic skin ulcer

* Tuberculosis - Acute

* Syphilis

* Skin cancer

* Sarcoidosis

* Leprosy

* Sporotrichosis

* Bacterial infection of skin

* Blastomycosis

* Yaws

* Cutaneous mycobacterium marinum infection

* Cutaneous anthrax

* Discoid lupus erythematosus

* Histoplasmosis - Acute

* Wegener's granulomatosis

* Lethal midline granuloma

* Paracoccidioidomycosis

* Behcet's syndrome

* Rhinoscleroma

 

Treatment  

 

Drug Therapy  

 

Treatment of cutaneous leishmaniasis  

 

ANTIMONY  

Adults: Intralesional infiltration greater than or equal to 1 mL per lesion, every other day for 8 to 15 injections or every 1 to 2 weeks for 3 to 8 injections (Leishmania major)

Adults: Intralesional infiltration greater than or equal to 1 mL per lesion weekly for 8 to 11 injections (L tropica)

Adults: 20 mg/kg/day IV or IM (sodium stibogluconate or meglumine antimonate) for 10 days (L major, L tropica, and L Mexicana mexicana)

Adults: 20 mg/kg/day IV or IM (sodium stibogluconate or meglumine antimonate) for 20 days (L Viannia complex , L mexicana) , (other Leishmania species)

 

PENTAMIDINE ISETHIONATE  

Adults: 2 mg/kg IM every other day for 7 injections OR 3 mg/kg IM every other day for 4 doses (L Viannia complex)

 

FLUCONAZOLE  

Adults: 200 mg orally once daily for 6 weeks (L major)

 

MILTEFOSINE  

Adults: 2.5 mg/kg/day orally for 28 days (L Viannia complex and L mexicana)

 

PAROMOMYCIN SULFATE  

Adults: apply topical ointment twice daily for 2 weeks ( L major) OR for 10 to 20 days (L (M) mexicana)

 

KETOCONAZOLE

Adults: 600 mg orally daily for 28 days (L Viannia complex and L mexicana)

 

AMPHOTERICIN B LIPOSOME  

Adults: 3 mg/kg/day for 6 days (L Viannia complex)

 

Treatment of cutaneous leishmaniasis in the immunosuppressed HIV-infected patient  

 

AMPHOTERICIN B LIPOSOME  

Adults: 2 to 4 mg/kg/day IV daily for 10 days OR interrupted schedule, such as 4 mg/kg/day IV on days 1 through 5 and on days 10, 17, 24, 31, and 38, to achieve a total dose of 20 to 60 mg/kg

 

ANTIMONY  

Adults: 20 mg/kg/day IV or IM (sodium stibogluconate or meglumine antimonate) for 3 to 4 weeks

 

 

Treatment of mucocutaneous leishmaniasis  

 

ANTIMONY  

Adults: 20 mg/kg/day IV or IM (sodium stibogluconate or meglumine antimonate) for 28 days (L Viannia complex or L Mexicana complex)

 

AMPHOTERICIN B

Adults: 1 mg/kg IV every other day for 20 infusions ((L Viannia complex or L Mexicana complex)

 

AMPHOTERICIN B LIPOSOME  

Adults: 3 mg/kg/day IV for 3 weeks (L Viannia complex)

 

PENTAMIDINE ISETHIONATE  

Adults: 3 mg/kg IM every other day for at least 15 doses (L Viannia complex)

 

Treatment of visceral leishmaniasis  

 

ANTIMONY  

Adults: 20 mg/kg/day IV or IM (sodium stibogluconate or meglumine antimonate) for 28 to 30 days

 

Treatment of visceral leishmaniasis in Bihar State, India or southeastern Nepal  

 

AMPHOTERICIN B

Adults: 1 mg/kg IV every other day for 15 doses OR daily for 20 days

 

AMPHOTERICIN B LIPOSOME  

Adults: 1 to 3 mg/kg/day IV for 5 days OR 5 to 7 mg/kg IV for one dose

Pediatric: 3 mg/kg/day IV infusion over 120 minutes on days 1 to 5 and on day 14 and 21

 

AMPHOTERICIN B LIPID COMPLEX  

Adults: 2 to 3 mg/kg/day IV for 5 days

 

PAROMOMYCIN SULFATE  

Adults: 16 to 20 mg/kg/day IM for 21 days

 

MILTEFOSINE  

Adults: 2.5 mg/kg/day orally for 28 days

 

Treatment of visceral leishmaniasis in the Mediterranean region  

 

AMPHOTERICIN B LIPOSOME  

Adults: 3 mg/kg/day IV for 5 days, then 10 mg/kg/day IV on days 10 and 11

 

Treatment of visceral leishmaniasis in the immunosuppressed HIV-infected patient  

 

AMPHOTERICIN B LIPOSOME  

Adults: 2 to 4 mg/kg/day IV daily for 10 days OR interrupted schedule, such as 4 mg/kg/day IV on days 1 through 5 and on days 10, 17, 24, 31, and 38, to achieve a total dose of 20 to 60 mg/kg

 

AMPHOTERICIN B LIPID COMPLEX  

Adults: 2 to 4 mg/kg/day IV daily for 10 days OR interrupted schedule, such as 4 mg/kg/day IV on days 1 through 5 and on days 10, 17, 24, 31, and 38, to achieve a total dose of 20 to 60 mg/kg

 

AMPHOTERICIN B

Adults: 0.5 to 1 mg/kg IV daily to achieve a total dose of 1.5 to 2 g

 

ANTIMONY  

Adults: 20 mg/kg/day IV or IM (sodium stibogluconate or meglumine antimonate) for 3 to 4 weeks

 

Chronic maintenance therapy following treatment of visceral leishmaniasis in the immunosuppressed HIV-infected patient  

 

AMPHOTERICIN B LIPID COMPLEX  

Adults: 3 to 4 mg/kg IV every 2 to 4 weeks

 

ANTIMONY  

Adults: 20 mg/kg IV or IM (sodium stibogluconate or meglumine antimonate) every 4 weeks

 

Post-kala-azar (disseminated visceral leishmaniasis) dermal leishmaniasis  

 

ANTIMONY  

Adults: 20 mg/kg/day IV or IM (sodium stibogluconate or meglumine antimonate) for a minimum of 30 days; treatment may need to be prolonged for 2 to 3 months

 

Procedural Therapy  

 

Cutaneous leishmaniasis  

* Thermotherapy

* Cryotherapy

 

Non-Procedural Therapy  

 

Primary prevention of Leishmaniasis  

* Vector/Reservoir Control