Transmission & Pathogenesis

A local granulomatous response leads to the formation of a crateriform lesion

The primary lesion may enlarge to 2cm or more in diameter, be intensely itchy, pruritic and
become subjected to secondary bacterial infections
Transfusion associated leishmaniasis has been reported has been documented but rare
Recovery depends on the development of a CMI response
Diffuse cutaneous leishmaniasis (DCL) may occur in patients with impaired immunity












Treatment and Prevention
Pantavalent antimony sodium gluconate (Pentostom) and Pentamidine isothionate (Lomidine)
Amphotericin B
Combination drug regimen exist using either Allopurinol or Gamma interferon along with
Pentostom
Length of therapy is species dependent

Life Cycle
The invading trypomastigotes actively enter histiocytes
(phagocytic cells of the RES) and other tissue cells
Parasite Transform into amastigotes and multiply by binary
fission
The parasites may transitionally pass through a promastigote,
epimastigote and trypomastigote form within the parasitized
cell

Trypanosoma cruzi
By day, this reduviid bugs live within the mud and thatch wall of dwellings and emerge at night
to feed on human blood
Trypanosomes develop in the gut of this insect and passed as they defecate while feeding
They bite painlessly about the face
Transmitted by triatomine bugs

Diagnosis
Demonstration of amastigotes of Leishmania in Giemsa stained smears of biopsy material from
the edge of an active ulcer
Culture methods will produce the promastigote stage
Complement-fixation, direct agglutination and Montenegro skin test

HEMOFLAGELLATE FORMS
Characteristic Amastigote Promastigote Epimastigote Trypomastigote
Size 5 x 3 m 9-15 m 9-15 m 12-35 m
Shape Oval to round Long and slender Long and slightly
wider
Spindle shaped, U
or C shaped in
blood films
Nucleus One,
eccentric
One,
central
One,
in posterior end
One,
anterior to
kinetoplast
Kinetoplast Present,
Consisting of dot-
like blepharoplast,
with small axoneme
and prabasal body
Anterior end of the
organism,
no undulating
membrane
Anterior to the
nucleus,
with half body
undulating
membrane
Posterior,
gives rise to full-
body length
undulation
membrane
Flagellum Absent Single, anterior free
flagellum
Single, anterior
free flagellum
Single, anterior free
flagellum

Transmission and Pathogenesis
The parasite has been acquired through blood transfusion, organ transplant or congenital trans.
infection is characterized by 3 progressive stages:
o Incubation period: few days to several weeks
o Hematogenous spread and lymphatic involvement
o Glandular stage: Winterbottoms sign, Kerandels sign

Leishmania chagasi
Visceral leishmaniasis in the New World (Central and South America)
Foxes and domestic dogs and cats serve as the natural reservoir
Sandflies of the genus Lutzomyia serve as the vector

Lab DX
Montenegro (Leishmanin) skin test is often used for the screening of large populations at risk.
The delayed hypersensitivity(HPS) reaction provoked by a suspension of killed leishmanial
promastigotes administered intradermally
A local inflammatory reaction appears at the site of injection within 48-72 hours in (+) patients
Serologic testing inc. IFA (indirect fluorescent antibody assay)

Transmission and Pathogenesis
L. garnhami and L. venezuelensis assosiated with cutaneous leishmaniasis in rural parts of
Venezuela
Infection with either organism present with a solitary lesion that is usually self-limiting
L. mexicana - produces a lesion known as chiclero ulcer or Bay sore common among workers
who collect chicle gum from the Chicazapote trees in the rain forest in Nicaragua, Guatemala,
Belize and the Yucatan peninsula of Mexico
Clinical manifestation: a single cutaneous papule, nodule or ulcer located on the ear or face
Lesions generally heal spontaneously but may cause cartilage destruction and gross
disfigurement

Transmission and Pathogenesis
Acute chagas dse is characterized by bouts of fever and chills, generalized malaise, myalgia
(mucle aches), fatigue and may appear in 4days to 2weeks following insect bite
Glandular enlargement and abdominal rash may also occur
Most severe symptoms are seen in very young children where course of infection is abbreviated
and S/S of CNS involvement appear early in infection
Marked myocarditis and damage to the CNS lead for eventual death

Transmission and Pathogenesis
Invading organism enter fat cells and are ingested by histiocytes and macrophages where they
transform into amastigotes and multiply
At the site of infection, an acute inflammatory response blocks lymphatic flow and produces an
erythematous primary lesion called chagoma
Trypomastigotes and amastigotes may be aspirated from chagoma

Lab DX
Elevated serum globulin levels
Complete Fixation test (CF), Direct agglutination tests(DAT), Indirect fluorescence technique
Montenegro skin test (not reactive in people with active disease)

Life Cycle
Similar to that of other Leishmanial organisms
Morphology is indistinguishable
Transmitted by sandflies of the genus Lutzomyia

Life Cycle
The infected hosts cell eventually ruptures releasing new parasites to infect additional host cells
Trypomastigotes periodically appear in the peripheral circulation as the infection spreads
beyond the regional lymph nodes
In the insect, T. cruzi is most commonly seen in the epistimastigote stage in the midgut and
transforms into the metacyclic trypomastigote which is excreted in the bugs feces

Lab DX
Trypomastigotes may be recovered in the peripheral blood during febrile episodes
Stained prep of lymph node aspirate may demonstrate the amastigote form
Xenodiagnosis
CF, EIA, IIFA, PCR, ELISA

Life Cycle
Glossina palpalis and Glossina tachinoides both male and female flies bite man and serve as
vector
Parasites are ingested by the fly when it takes a blood meal on an infected mammal, humans or
ungulate (hoofed animals)
In the fly, the parasite begins to multiply, develops in the gut and salivary glands

Lab DX
Demonstration of the non-flagellated amastigote by Giemsa stain from spleen and liver biopsies
Bone marrow and lymph nodes aspirations are advised
Culture sample will yield promastigotes
Buffy coat preps may reveal intracellular amastigotes

Treatment and Prevention
Pentavalent sodium antimony (Pentostam)
Cycloguanil pamoate (Camolar) and Amphotericin B
Protective clothing, insect repellent, vector control, control of reservoir host, public health
educational program

Transmission and Pathogenesis
Most common victim is <5 years old
As the insect bites, it deposits infective material near the bite wound
The bite wound becomes intensely pruritic and T. cruzi is scratched into the bite wound
incubation period: 7-14 days
An acute local inflammatory reaction results as the organism is carried by the lymphatic to the
regional lymph nodes

Treatment and Prevention
Melarsoprol. Trivalent arsenic compound much more toxic than Pentamidine or Suramin but is
the drug of choice for the later stageof Gambian sleeping sickness. Administered IV and can
penetrate the BBB
Tsetse flies are attracted tp bright and darf colors; thick khaki or olive drab clothing is preferred
Use of bed nets and insect repellant

Treatment and Prevention
Sodium stibogluconate (antimony sodium gluconate: Pentostam) administered IM for 10 days
May require multiple courses of treatment to induce a clinical response
Alternate drug of choice: meglumine antimonite or Glucantime, Amphotericin B, Ketoconazole
Prevention lies in vector and reservoir

Transmission and Pathogenesis