Leushmaniosis

Description:

Leyshmanioza (Latin Leishmaniasis) - group of the parasitic natural and focal, generally zoonotic, transmissible diseases widespread in the tropical and subtropical countries; is caused by the parasitizing protozoa of the sort Leishmania who are transmitted to the person through stings of mosquitoes.

According to World Health Organization, leyshmanioza meet in 88 countries of the Old and New World. From them 72 treat developing countries, and among these thirteen are the poorest countries of the world. The visceral leushmaniosis meets in 65 countries.

Leushmaniosis symptoms:

According to features of clinic, an etiology and epidemiology of a leyshmanioza subdivide into the following types.

Visceral leushmaniosis (kala azar)
1. Zoonotic: Mediterranean and Central Asian (children's kala azar), east African (fever of thoughts thoughts), skin and mucous leushmaniosis (leushmaniosis of the New World, nasopharyngeal leushmaniosis).
2. Antroponozny (Indian kala azar).

Skin leushmaniosis
1. Zoonotic (rural type of a disease Bohr, pendinsky ulcer).
2. Antroponozny (city type of a disease Bohr, Ashgabat ulcer, Baghdad furuncle).
3. Skin and skin and mucous leushmaniosis of the New World (espundia, disease of Breda).
4. Ethiopian skin leushmaniosis.

Visceral Mediterranean and Asian leushmaniosis.
Incubation interval. Varies from 20 days to 3-5 months, in rare instances till 1 year and more. Children of early age and seldom at adults long before the general displays of a disease have primary affect in the form of a papule.

Initial stage of a disease. Gradual development of weakness, a loss of appetite, an adynamia, pallor of integuments, small increase in a spleen are characteristic. Slightly body temperature increases.

Heat period. Usually begins with rise in body temperature to 39-40 °C. Fever accepts wavy or wrong character and lasts from several days to several months with change of episodes of high temperature and remissions. In some cases body temperature within the first 2-3 months happens subfebrile or even normal.

At survey of patients define a polylymphadenopathy (peripheral, peribronchial, mezenterialny and other lymph nodes), increase and consolidation of a liver and even more spleens, painless at a palpation. In cases of development of a bronkhadenit cough is possible, pneumonia of secondary and bacterial character is frequent.

In process of the course of a disease the condition of patients progressively worsens. Develop weight loss (up to a cachexia), a hypersplenism. Damages of marrow lead to the progressing anemia, a granulocytopenia and an agranulocytosis, sometimes with a necrosis of mucous membranes of an oral cavity. Quite often there are manifestations of a hemorrhagic syndrome: hemorrhages in skin and mucous membranes, bleedings from a nose, a GIT. Fibrous changes in a liver lead to portal hypertensia with hypostases and ascites that is promoted by the progressing hypoalbuminemia.

Owing to a hypersplenism and high standing of a diaphragm heart is a little displaced to the right, its tones become deafs, tachycardia and arterial hypotension develop. These changes along with anemia and intoxication lead to emergence and increase of symptoms of heart failure. Diarrhea, disturbances of a menstrual cycle, impotence are possible.

Terminal period. Observe a cachexia, falling of a muscle tone, thinning of skin, development of protein-free hypostases, sharp anemia.

The disease can be shown in acute, subacute and chronic forms.
• Acute form. Occasionally meet at small children. Develops violently, without treatment quickly comes to an end with a lethal outcome.
• Subacute form. Meet more often. The heavy clinical manifestations lasting 5-6 months are characteristic.
• Chronic form. Develops most often, quite often proceeds subclinically and latentno.

At a visceral antroponozny leushmaniosis (the Indian kala azar) 10% of patients in several months (till 1 year) after therapeutic remission on skin have so-called leishmanoids. They represent small small knots, papillomas, erythematic spots or sites of skin with the lowered pigmentation in which contain a leushmania for a long time (years and decades).

Skin zoonotic leushmaniosis (pendinsky ulcer, disease Bohr). Meet in the tropical and subtropical countries. The incubation interval varies of 1 week up to 1,5 months, averages 10-20 days. In the place of entrance gate there is primary leishamanioma in the beginning representing a smooth papule of pink color with a diameter of 2-3 mm. The hillock sizes quickly increase, at the same time it sometimes reminds a furuncle, but painless or poorly painful at a palpation. In 1-2 weeks in the center of a leishamanioma the necrosis reminding an abscess head begins and then the erethistic ulcer to 1-1,5 cm in the diameter, with the subdug edges, a powerful rim of infiltrate and plentiful serous and purulent or sanious exudate is formed; Around it the small secondary hillocks, so-called "hillocks of planting" which are also ulcerating often form and at merge the forming ulcer fields. So the consecutive leishamanioma forms. Leishamaniomas are more often localized on open parts of a body, their quantity varies up to tens from units. Formation of ulcers in many cases accompanies development of painless limfangit and lymphadenites. In 2-6 months epithelization of ulcers and their scarring begin. The general duration of a disease does not exceed 6-7 months.

Diffusion инфильтрирующий leushmaniosis. It is characterized by the expressed infiltration and a thickening of skin with a big zone of distribution. Gradually infiltrate resolves without trace. Small ulcerations observe only in exceptional cases; they begin to live with formation of scarcely noticeable hems. This option of a skin leushmaniosis is met very seldom at elderly people.

Tuberculoid skin leushmaniosis. Sometimes observe at children and young faces. It differs in education around hems or on them small hillocks. The last can increase and merge with each other. In dynamics of a disease they occasionally ulcerate; in the subsequent ulcers heal with scarring.

Skin anptroponozny leushmaniosis. Differs in a long incubation interval in several months or even years and two main features: slow development and smaller expressiveness of skin defeats.

Complications and forecast
Pneumonia can complicate the started leushmaniosis, it is purulent - necrotic processes, nephrite, an agranulocytosis, hemorrhagic diathesis. The forecast of the heavy and complicated forms of a visceral leushmaniosis at untimely treatment often adverse. At easy forms perhaps spontaneous recovery. In cases of a skin leushmaniosis the forecast for life favorable, but cosmetic defects are possible.

Leushmaniosis reasons:

Leushmaniosis activators - the simplest families Leishmania of the Trypanosomidae family of the class Mastigophora. Now allocate several tens of types of leyshmaniye; ability to cause damages at the person is shown by 17 types. Leyshmany - the intracellular parasites developing in macrophages or cells of reticuloendothelial system. A life cycle of leyshmaniye proceeds with change of owners in the form of two stages - aflagellar (amastigotny) in an organism of a vertebrate animal or the person and flagellar (promastigotny) - in an arthropod organism. Breed by longitudinal division, morphologically leyshmany are indiscernible. Dermatotropic types of leyshmaniye (L. tropica, L. major, L minor, L. aethiopica, etc.) cause skin forms of a leushmaniosis. At infection with viscerotropic parasites (L. donovani, L. infantum, L. chagasi, etc.) the system, chronically proceeding disease develops. The majority of types of leyshmaniye is easy to cultivate in vitro. In cultures of cells at 37 °C they grow in a look амастигот, having the oval form, on acellular environments at 22-27 °C - in a look промастигот a spindle-shaped form. A leushmania are insensitive to antibiotics, it is slightly more - to derivatives of pentavalent antimony.

Tank and sources of an invasion - the person and various animals. Among the last jackals, foxes, dogs and rodents have the greatest value (sandworts - big, redtailed, midday, a tonkopaly gopher, etc.). Transmissibility lasts vaguely long time and is equal to the period of stay of the activator in blood and ulcerations of skin of the owner. Duration of a skin leushmaniosis at sandworts usually makes about 3 months, but can reach 7 months and more.

The transfer mechanism - transmissible, carriers - mosquitoes of the sorts Phlebotomus and Lutzomyia. The mosquito of P. papatasii leading in most cases synanthropic existence is well studied as a carrier of a city leushmaniosis. The main places of breeding of mosquitoes in settlements - cellars in premises and garbage dumps, in the nature - nests of birds, dens of animals, holes of rodents, caves, cracks of rocks. In the natural centers the main carriers of a leushmania are P. papatasii, P. caucasicus, P. sergenti. Mosquitoes are active in twilight and night time. At skin forms of an invasion mosquitoes catch on leishamaniomas - the daddy or an ulcer at the person, on reinforced or ulcerated sites of ears at sandworts and other animals. At visceral forms of a leushmaniosis at the person parasites are usually inaccessible for mosquitoes therefore the patient seldom is a source to an invasion. The exception makes the Indian kala azar at which a leushmania quite often find in the blood and skin defeats developing in the disease outcome. A leushmania get to an organism of a mosquito at suction of blood of the infected person or an animal in whose stomach in several hours of an amastigota turn into promastigota. Infectious mosquitoes become in 5-8 days after hit of the infected blood in a stomach and remain leushmania carriers for life. Development of mosquitoes is implemented by a complete metamorphosis: egg-larva-doll-imago. Cases of transfer of a leushmania at hemotransfusions are noted.

Natural susceptibility of people high. Immunity has specific character. Intense postinfectious immunity is developed only after a skin leushmaniosis. Various states which are followed by immunodeficiencies significantly reduce resistance to parasites.

Main epidemiological signs of a leushmaniosis. The Indian visceral leushmaniosis (kala azar) caused by L. donovani is antroponozy. It is widespread in a number of the regions of Pakistan, Bangladesh, Nepal, China, etc. It is distinguished by the disease outbreaks arising from time to time. Teenagers and the young faces mainly living in rural areas are ill preferential.

The Mediterranean and Central Asian visceral leushmaniosis caused by L. infantum is a zoonosis, an infection tank in the nature - jackals, foxes, dogs. It is widespread in a number of the countries of the Mediterranean, the Middle East, Africa, Kazakhstan, Central Asia and Transcaucasia. Allocate natural, semi-synanthropic (rural type) and synanthropic (city type) the invasion centers. Infection occurs most often in the summer, children from 1 year to 5 years of life are ill generally. In recent years in connection with wide circulation of HIV infection, a combination leyshmaniozny and HIV infections there were essential changes in clinical and epidemiological manifestations of a leushmaniosis. Against the background of HIV infection concentration of leyshmaniye in blood and integuments of patients sharply increases. Such patients, replacing sick dogs, began to play an invasion source role for carriers. The Mediterranean visceral leushmaniosis from a typical zoonosis turned into a transmissible antroponoz. Maintenance of circulation of the activator became possible in a chain: the sick person - a mosquito - the healthy person. At the same time in process of development of epidemic of HIV infection there was a further simplification of the scheme of development of epidemic process. Increase in number of the parenteral addicts infected with HIV and leyshmaniye promoted formation of direct injection transfer of a visceral leushmaniosis. In this case there was a limit simplification of parasitic system of a visceral leushmaniosis: the sick person - the healthy person. As a factor of transfer serve the infected syringes.

The South American visceral leushmaniosis (visceral leushmaniosis of the New World) caused by L. chagasi is close on the manifestations to Mediterranean Central Asian leushmaniosis. Note generally sporadic incidence in a number of the countries of Central and South America.

The Antroponozny skin leushmaniosis of the Old World (a disease Bohr) caused by L. minor is widespread in the Mediterranean, the countries of the Middle East, in the western part of the peninsula of Hindustan, Central Asia and Transcaucasia. The disease meets preferential in the cities and settlements of city type where mosquitoes live. Among local population children, among visitors - persons of all age are ill more often. Aestivo-autumnal seasonality is characteristic that is connected with activity of carriers.

The zoonotic skin leushmaniosis of the Old World (pendinsky ulcer) is caused by L. major. The main tank of an invasion - rodents (a big and red sandwort, etc.). It is widespread in the countries of the Middle East, North and Western Africa, Asia, in Turkmenistan and Uzbekistan. The endemic centers meet mainly in the desert and the semi-desert, in rural areas and on suburbs of the cities. Summer seasonality of infections is defined by the period of activity of mosquitoes. Children are ill preferential, among visitors the outbreaks of diseases among persons of different age are possible.

The zoonotic skin leushmaniosis of the New World (the Mexican, Brazilian and Peruvian skin leyshmanioz) caused by L. mexicana, L. braziliensis, L. peruviana, L. uta, L. amazoniensis, L. pifanoi, L. venezuelensis, L. garnhami, L. panamensis is registered in Central and South America, and also in the southern regions of the USA. A natural tank of activators - rodents, numerous wild and domestic animals. Diseases are met in rural areas, it is preferential during a rainy season. Persons of all age get sick. Usually infection occurs at the time of work in the wood, hunting, etc.

Treatment of the Leushmaniosis:

At a visceral leushmaniosis use drugs of pentavalent antimony (Solusurminum, Neostibosanum, glyukanty, etc.) in the form of daily intravenous injections in the accruing doses since 0,05 g/kg. The course of treatment makes 7-10 days. At insufficient clinical performance of drugs appoint Amphotericinum In on 0,25-1 mg/kg slowly intravenously in 5% glucose solution; the drug is administered every other day a course to 8 weeks. Pathogenetic therapy and prevention of bacterial complications is carried out according to well-known schemes.

In cases of a skin leushmaniosis at an early stage of a disease carry out an obkalyvaniye of hillocks by solutions of Mepacrinum, Monomycinum, urotropin, berberine sulfate; apply ointments and lotions with use of these means. At the created ulcers appoint intramuscular injections of Monomycinum on 250 thousand. Piece (to children on 4-5 thousand. Piece/kg) 3 times a day, the course dose of drug makes 10 mln units. It is possible to carry out treatment by Aminochinolum (on 0,2 g 3 times a day, on a course - 11-12 g of drug). Apply laser radiation of ulcers. Drugs of pentavalent antimony and Amphotericinum In are appointed only in hard cases of a disease.

Choice drugs: antimonyl a gluconate sodium on 20 mg/kg in/in or 1 time in oil a day a course for 20-30 days; меглумин антимониат (glyukanty) on 20-60 mg/kg of 1 times deeply in oil a day a course on 20-30 days. At a recurrence of a disease or insufficient efficiency of treatment it is necessary to conduct a repeated course of injections within 40-60 days. Effectively additional purpose of Allopyrinolum on 20-30 mg/kg/days in 3 intakes.

Alternative drugs at a recurrence of a disease and resistance of the activator: Amphotericinum In on 0,5-1,0 mg/kg in/in every other day or pentamidine in oil of 3-4 mg/kg 3 times a week a course on 5-25 weeks. In the absence of effect of chemotherapy in addition appoint human recombinant at - interferon.

Surgical treatment. According to indications carry out a splenectomy.