Leishmaniasis and rheumatic disease 4.2/5 (5)

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Leishmaniasis (ICD-10 B55)

Definition

Tropical disease caused by the leishmania protozoans belonging to the parasite group flagellates. Kala-Azar ("Black fever") corresponds to the visceral form. Joint and muscle pain can be part of the disease picture. People with a weakened immune system, such as when using immunosuppressive drugs for rheumatic disease, can get sick more easily.

Three main types:

  1. Visceral type (spleen, liver, anemia, fever) (Kala Azar)
  2. Cutaneous form (orient wound)
  3. Mucocutaneous form (mouth and mucous membranes)

Occurrence

Insidence in Norway: Leishmaniasis was required to be reported in MSIS 1975-94. During this period MSIS reported 4 cases of visceral leishmaniasis. Infection site in all cases was Spain in persons of Norwegian origin.

Visceral leishmaniasis (Kala-Azar = black fever)

  • Mediterranean countries, Middle East (including Turkey)
  • China (Leishmania infantum)
  • Indian subcontinent
  • East Africa (L.donovani)
  • South and Central America (L.chagasi)
  • 90% of cases in the world occur in Bangladesh, Brazil, India, Nepal and Sudan
  • Children are most affected in the Mediterranean, most adults are affected in India and Africa
  • 500 new cases of visceral leishmaniasis annually
  • Dogs and other animals are reservoirs in the Mediterranean countries
  • People's only reservoir on the Indian subcontinent

Kutan leishmaniasis

  • Mainly in South and Central America (L. brasiliensis)
  • Mediterranean and Middle East (L.tropica and L.major)
  • 90% of cases in the world occur in Afghanistan, Algeria, Brazil, Iran, Peru, Saudi Arabia, and Syria
  • 1,5 million new cases of cutaneous leishmaniasis annually

Both forms of leishmaniasis may occur in Norway as imported cases.

Contamination

  • Increased risk of infection for persons with reduced immune system
  • Bite of sandflies transmits infection
  • Sand flies are found mainly in dry and semi-dry areas in villages, underground rodent marshes, scrub forests and rocky rocks, in South America also in tropical forests. The flies have a short action radius
  • The reservoir for the parasite is human and animal, and vector is blood-sucking butterflymosquito of the genera Phlebotomus and Lutzomyia, so-called sandflies
  • Woundmaterial by the cutaneous type may in rare cases infect one person to another
  • The parasite can also be transmitted through the use of unclean syringes
  • The genus Phlebotomus occurs in Europe, Asia and Africa and Luzomyia in South America

Incubation time (from infection to symptom)

  • Skin: Cutaneous form: from 1 week to several months
  • Internal organs: Visceral form: from 2 - 6 months

Symptoms and course 

Visceral form (mostly in the stomach and intestines)

  • Systemic disease
  • May be a serious course
  • Fever over weeks without response to steroids
  • Diarrhea and weight loss
  • Medical investigation and findings
    • Enlarged spleen and liver (hepatosplenomegaly)
    • Large lymph nodes
    • Anemia and pancytopenia (low blood cell count indicating bone marrow infiltration)
    • Dark pigmentation in the skin may occur in palms or temples

Cutaneous form (mostly skin)

  • Development of reddish-brown nodules with central ulceration ("oriental ulcer")
    • In the face
    • On the shoulders or upper arm

Mucocutaneous form (mostly in mucous membranes and skin)

  • Wounds in the mucous membrane can erode the palate and nasal septum over the years

Rheumatic symptoms

  • Joint pain
  • Muscle pain

Diagnostics

  • Detection of protozoa by direct microscopy of ulcer, liver, bone marrow or lymph node biopsy
  • PCR tests
  • Nucleic acid amplification tests for detection in blood have been developed

Treatment

Systemic, specific antibiotic treatment (antimony preparations) against both forms of the disease.

Preventive measures

  • Covering the body to avoid stinging. There is no vaccine.
  • No special measures on imported cases. People who have or have had Kala-Azar (Visceral form) are permanently excluded from blood donation. Not notifiable to Norwegian MSIS.

Literature

Tropic diseases, BINDEVEVSSYKDOMMER.no


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