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Leishmaniasis

para>Miltefosine (Impavido) contraindicated in pregnancy ‚

SURGERY/OTHER PROCEDURES

Adjunctive splenectomy or reconstructive surgery for tissue damage (MCL) ‚

INPATIENT CONSIDERATIONS

Inpatient care for blood transfusions, complicating superinfections, frequent IV medication, and monitoring for adverse effects ‚

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

  • Follow-up at 6 weeks, 3 months, and 12 months to evaluate treatment effectiveness and to detect relapses.Lesion size should decrease by 2/3 by 6 weeks. If 1/3 to 2/3 decrease, continue observation on current therapy or change regimen; if <1/3 decrease, change regimen.
  • PKDL should be treated like initial illness.
  • Periodic monitoring of ECG, liver function, and renal function during prolonged therapy

PATIENT EDUCATION

www.cdc.gov/parasites/leishmaniasis ‚

PROGNOSIS

  • Variable, depending on species, disease type, and host factors (i.e., immune status). Localized CL may resolve without treatment. CL cure rate of 76% with pentavalent antimonials (4)
  • VL mortality is ~90% untreated/~10% treated (3).
  • Mucocutaneous: 30 " “90% cure rate if treated early, may lead to permanent disfiguration (6)

COMPLICATIONS

  • Cutaneous: secondary bacterial infections; scarring; development of MCL with disfigurement and scarring; adverse effects of treatment
  • Visceral: PKDL in 3 " “10% of kala azar cases; secondary bacterial infections; GI bleeding, hemorrhage, disseminated intravascular coagulation (DIC) " ”may require transfusions; nephrotic syndrome, glomerulonephritis; cirrhosis, acute liver failure; persistent splenomegaly; death

REFERENCES

11 Alvar ‚ J, Velez ‚ ID, Bern ‚ C, et al. Leishmaniasis worldwide and global estimates of its incidence. PLoS One. 2012;7(5):e35671.22 Srivastava ‚ P, Dayama ‚ A, Mehrotra ‚ S, et al. Diagnosis of visceral leishmaniasis. Trans R Soc Trop Med Hyg. 2011;105(1):1 " “6.33 Stockdale ‚ L, Newton ‚ R. A review of preventative methods against human leishmaniasis infection. PLoS Negl Trop Dis. 2013;7(6):e2278.44 Alavi-Naini ‚ R, Fazaeli ‚ A, O 'Dempsey ‚ T. Topical treatment modalities for old world cutaneous leishmaniasis: a review. Prague Med Rep. 2012;113(2):105 " “118.55 Tiuman ‚ TS, Santos ‚ AO, Ueda-Nakamura ‚ T, et al. Recent advances in leishmaniasis treatment. Int J Infect Dis. 2011;15(8):e525 " “e532.66 Goto ‚ H, Lindoso ‚ JA. Current diagnosis and treatment of cutaneous and mucocutaneous leishmaniasis. Expert Rev Anti Infect Ther. 2010;8(4):419 " “433.

ADDITIONAL READING

  • Cota ‚ GF, de Sousa ‚ MR, Demarqui ‚ FN, et al. The diagnostic accuracy of serologic and molecular methods for detecting visceral leishmaniasis in HIV infected patients: meta-analysis. PLoS Negl Trop Dis. 2012;6(5):e1665.
  • Mitropoulos ‚ P, Konidas ‚ P, Durkin-Konidas ‚ M. New world cutaneous leishmaniasis: updated review of current and future diagnosis and treatment. J Am Acad Dermatol. 2010;63(2):309 " “322.
  • Tuon ‚ FF, Amato ‚ VS, Graf ‚ ME, et al. Treatment of new world cutaneous leishmaniasis " ”a systematic review with a meta-analysis. Int J Dermatol. 2008;47(2):109 " “124.

CODES

ICD10

  • B55.9 Leishmaniasis, unspecified
  • B55.1 Cutaneous leishmaniasis
  • B55.0 Visceral leishmaniasis
  • B55.2 Mucocutaneous leishmaniasis

ICD9

  • 085.9 Leishmaniasis, unspecified
  • 085.4 Cutaneous leishmaniasis, American
  • 085.0 Visceral [kala-azar] leishmaniasis
  • 085.5 Mucocutaneous leishmaniasis, (American)
  • 085.1 Cutaneous leishmaniasis, urban
  • 085.2 Cutaneous leishmaniasis, Asian desert
  • 085.3 Cutaneous leishmaniasis, Ethiopian

SNOMED

  • leishmaniasis (disorder)
  • cutaneous leishmaniasis (disorder)
  • visceral leishmaniasis (disorder)
  • American cutaneous/mucocutaneous Leishmaniasis
  • Asian desert cutaneous leishmaniasis
  • Diffuse cutaneous leishmaniasis
  • Dry form of cutaneous leishmaniasis

CLINICAL PEARLS

  • A nonhealing cutaneous ulcer in a patient with the appropriate history of travel to endemic area is leishmaniasis until proven otherwise.
  • Consider VL in febrile travelers with organomegaly.
  • Preventive measures to avoid sandfly bites are important for travelers.
  • Previous infection does not confer significant immunity.
  • Military deployed to Iraq/Afghanistan is at higher risk.
  • In the United States, CL cases are mainly in Texas and Oklahoma.