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Infectious Diseases

Leishmaniasis

A group of parasitic diseases caused by protozoa of the genus Leishmania, transmitted by the bite of infected female phlebotomine sandflies. Manifests as visceral, cutaneous, or mucocutaneous forms.

Also known as: Kala-azar (Visceral), Oriental Sore (Cutaneous)

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Referral and warning signs

When to refer

Refer ALL suspected cases of Leishmaniasis (Visceral or complex Cutaneous) URGENTLY to Referral Hospital (RR) with diagnostic capability (including tissue aspiration) and access to appropriate specific medications (SSG, Paromomycin, Amphotericin B).

Red flags

  • Prolonged fever + Massive splenomegaly + Wasting (VL).
  • Signs of severe pancytopenia (severe pallor, bleeding, infections).
  • Non-healing skin ulcer from endemic area.
  • Signs of mucocutaneous involvement.

Signs and symptoms

  • Visceral Leishmaniasis (VL / Kala-azar):
  • - Chronic systemic illness.
  • - Prolonged, irregular fever (often double daily peaks).
  • - Marked splenomegaly (often massive) and hepatomegaly.
  • - Lymphadenopathy.
  • - Progressive weight loss / Emaciation / Cachexia.
  • - Weakness, fatigue.
  • - Anaemia (pallor), Leucopenia, Thrombocytopenia -> Pancytopenia.
  • - Darkening of the skin (hyperpigmentation - 'kala-azar' means black fever).
  • - Symptoms develop over months; fatal if untreated.
  • - Post-Kala-azar Dermal Leishmaniasis (PKDL): Skin lesions (macules, papules, nodules) appearing months to years after VL treatment.
  • Cutaneous Leishmaniasis (CL / Oriental Sore):
  • - Starts as papule at bite site.
  • - Enlarges over weeks/months to form a nodule or ulcer.
  • - Ulcer typically painless, indurated borders, may have crust.
  • - Lesions usually on exposed skin (face, arms, legs).
  • - May heal spontaneously over months to years, leaving a scar.
  • - Diffuse cutaneous form (multiple non-ulcerating nodules - anergic response).
  • Mucocutaneous Leishmaniasis (MCL / Espundia):
  • - Primarily in South America.
  • - Destructive lesions of nose, mouth, throat mucosa, occurring months/years after initial cutaneous lesion.
  • - Nasal stuffiness/bleeding, progressing to septal perforation, cartilage destruction ('tapir nose').

Risk factors

  • Living in or travelling to endemic areas (parts of Asia, Africa, Middle East, Mediterranean, Americas).
  • Exposure to sandfly bites (often dusk/dawn).
  • Poor housing conditions.
  • Malnutrition.
  • Immunosuppression (HIV co-infection increases risk and severity of VL).

Diagnosis

Clinical assessment

VL: Suspect in patient from endemic area with prolonged fever, hepatosplenomegaly, weight loss, pancytopenia. CL: Characteristic skin ulcer/nodule in endemic area.

Differential diagnosis

  • VL: Malaria, Typhoid, Brucellosis, TB (disseminated), Lymphoma, Leukemia, Schistosomiasis (advanced), HIV/AIDS.
  • CL: Other skin ulcers (bacterial, fungal, mycobacterial - TB/leprosy), Insect bite reaction, Skin cancer, Sarcoidosis.

Investigations

  • Demonstration of Parasite (Leishman-Donovan bodies - amastigotes inside macrophages):
  • - VL: Splenic aspirate (highest sensitivity, but risk of bleeding - specialist procedure), Bone marrow aspirate/biopsy (safer, good sensitivity), Lymph node aspirate. Stained smears (Giemsa).
  • - CL: Slit-skin smear or biopsy from lesion edge (stained smear/histology).
  • - Culture: From aspirates/biopsy material (specialized media).
  • Serology (Antibody detection - VL):
  • - rK39 rapid diagnostic test (ICT strip): Good sensitivity/specificity for VL diagnosis, widely used.
  • - ELISA, IFA, DAT (Direct Agglutination Test).
  • PCR: Detection of Leishmania DNA in blood, bone marrow, tissue (highly sensitive, specialized labs).
  • Leishmanin Skin Test (Montenegro test): Delayed hypersensitivity test. Positive in CL/MCL and past VL, but NEGATIVE in active VL (due to anergy).
  • FBC (pancytopenia in VL), LFTs.

Diagnostic criteria

VL: Clinical suspicion + Positive serology (esp. rK39) OR Demonstration of parasite in tissue aspirate/biopsy. CL: Characteristic lesion + Demonstration of parasite.

Management

Non-pharmacological management

  • Supportive care: Nutritional support, Treat anaemia (transfusion if severe), Manage secondary infections.

Pharmacological treatment

  • Requires Specialist Management (Referral Centre - RR): Treatment depends on Leishmania species, clinical form (VL/CL/MCL), geographic region, patient factors (HIV co-infection).
  • Visceral Leishmaniasis (VL / Kala-azar):
  • - First Line (East Africa/Uganda - UCG): Combination Therapy: Sodium Stibogluconate (SSG) 20mg/kg/day IM/IV PLUS Paromomycin 15mg/kg/day IM (11mg/kg base) - BOTH for 17 DAYS.
  • - Alternative First Line (if Paromomycin C/I): SSG 20mg/kg/day IM/IV for 30 DAYS.
  • - Alternative / Relapse / Pregnancy / HIV Co-infection: Liposomal Amphotericin B (AmBisome) IV. Dose varies (e.g., 3mg/kg/day x 10d OR single high dose OR multiple doses total 20-30mg/kg). Preferred agent due to efficacy/lower toxicity but high cost/availability issues.
  • - Other options: Miltefosine (oral), Combination regimens.
  • - Monitoring: Requires careful monitoring for drug toxicity (SSG: cardiotoxicity-ECG, pancreatitis, renal; Ampho B: nephrotoxicity, infusion reactions, electrolyte loss). Monitor clinical response, parasite clearance (repeat aspirates).
  • Cutaneous Leishmaniasis (CL):
  • - Many Old World CL cases self-heal. Treatment considered for large, multiple, persistent, disfiguring lesions, or specific species.
  • - Local therapy: Intralesional SSG injection, Cryotherapy, Thermotherapy.
  • - Systemic therapy (if severe/refractory): SSG, Fluconazole, Itraconazole, Miltefosine, Amphotericin B (choice depends on species/location).
  • Post Kala-Azar Dermal Leishmaniasis (PKDL): Requires prolonged treatment, often with SSG or Liposomal Amphotericin B. (Rare in Uganda per UCG).

Monitoring

Monitor clinical response (fever, spleen size, weight gain). Monitor parasite clearance (repeat smears/aspirates if VL). Monitor for drug toxicity. Follow up for relapse.

Complications

  • VL: Severe malnutrition/cachexia, Severe anaemia/pancytopenia, Secondary infections (pneumonia, TB, sepsis), Bleeding, Liver failure, Death.
  • CL: Secondary bacterial infection, Scarring, Disfigurement.
  • MCL: Severe facial disfigurement, difficulty breathing/swallowing.
  • PKDL.
  • Relapse.

Prevention

  • Vector Control: Insecticide spraying (indoor residual spraying - IRS), Insecticide-treated bed nets (ITNs).
  • Personal Protection: Avoid outdoor activities dusk/dawn, wear protective clothing, use insect repellent (DEET).
  • Reservoir Control: Treatment of human cases (VL), control of animal reservoirs (dogs for some types).
  • Environmental management (clearing breeding sites - less effective for sandflies).
  • Early diagnosis and treatment.

Patient education

  • Explanation of the disease, transmission by sandfly.
  • Need for specific diagnosis (often involving aspirate/biopsy).
  • Importance of completing prolonged course of medication.
  • Potential drug side effects and need for monitoring.
  • Prevention measures (bed nets, repellent).
  • Nutritional support.

Uganda-specific notes

Visceral Leishmaniasis (Kala-azar) is endemic in specific regions, particularly Karamoja. Cutaneous forms less common. Diagnosis relies on clinical suspicion, rK39 RDT, and confirmation via splenic/bone marrow aspirate microscopy where feasible. SSG + Paromomycin is standard first-line regimen.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 2, Section 2.5.1

For learning and professional reference. Use current local guidance and clinical judgement.

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