Leishmaniasis. Leishmaniasis: causes, symptoms, diagnosis, treatment and prevention Mucocutaneous form of the disease

Very often, people are faced with skin diseases: either a rash appears, or wounds, or it’s not yet clear what, it seems like a bite, but it’s somehow strange. Very often, a mosquito bite can develop into an infection, one of the forms of which is such a disease as leishmaniasis. It is about this disease that we will talk today. So what is leishmaniasis?

concept

Leishmaniasis is an infection that manifests itself not only in humans, but also in animals. It is caused by protozoa of the genus Leishmania and is transmitted by the bite of Lutzomyia mosquitoes.

The simplest Leishmania are distributed mainly in hot countries: Asia, Africa, South America.

Most often, already infected people, domestically raised canines (foxes, wolves or jackals), and rodents can be the most common sources of the disease.

With a difficult and long healing process, dangerous not only for humans, but also for animals, is etolishmaniasis. bacteria that cause this disease is very long. Mosquitoes are the first to infect. After that, the infection enters the digestive system, where the not yet fully mature forms of leishmaniasis mature and turn into a mobile flagellar form. Accumulating in the mosquito's larynx, during a new bite, they enter the wound and infect the epithelial cells or or the animal.

Leishmaniasis: varieties

There are several types of this disease, and each of them is dangerous in its own way for the human body:

• Cutaneous.
• Slimy.
• Visceral leishmaniasis.
• Skin-mucous.
• Viscerotropic.

The main symptoms of leishmaniasis

The main symptoms of this disease are ulcers on the human body. They can appear in a few weeks and even months after he is bitten by an insect carrier of the infection. Another symptom of the disease can be fever, which can also begin a few days after the bite. Time can pass enough, in some cases up to a year. Also, the disease affects the liver and spleen, and anemia may be a consequence.

In medicine, the first sign of leishmaniasis is an enlarged spleen: it can become larger in size than the liver. To date, there are 4 forms of leishmaniasis:

1. Visceral. This is one of the most difficult forms of the disease. If you do not start prompt treatment, the disease can lead to death.
2. Cutaneous leishmaniasis. It is considered one of the most common forms. Immediately after the bite, pain appears in its place. This form of the disease can be cured only after a few months, and even after that the person will remember it, looking at the scar left from the disease.
3. Diffuse cutaneous leishmaniasis - this form of the disease is widespread, its appearance strongly resembles leprosy and is very difficult to treat.
4. Slimy form. It begins with which further lead to tissue damage, especially in the oral cavity and nose.

The concept and symptoms of visceral leishmaniasis

Visceral leishmaniasis is a form of the infectious disease caused by leishmania. An ailment occurs when this type of microbes spreads by the hematogenous route from the primary focus of infection to any of the human organs: the liver, spleen, lymph nodes, and even to the bone marrow. Microorganisms in the body multiply very quickly, which leads to its damage.

Most often this disease affects children. The incubation period is quite long, sometimes lasting up to five months. The disease begins slowly, but in the category of infected people who come to endemic areas, the disease can develop rapidly.

Visceral leishmaniasis symptoms are quite common. In almost all patients they are the same: general malaise, weakness throughout the body, lethargy, full fever begins very quickly. It passes in a wave, while the body temperature can reach 40 degrees. Then comes a slight relief of the state, which is again replaced by a high temperature, which is also very difficult to bring down.

You can also see signs of a disease such as visceral leishmaniasis on the skin. Symptoms are as follows: pale skin with a grayish tinge and often with hemorrhages. It is worth paying attention to the lymphatic system - the lymph nodes will be enlarged.

The main signs of visceral leishmaniasis

The main symptom of the disease is the initial defect, which may be single, and therefore may not be noticed at the first examination. It looks like a small, hyperemic papule, covered with scales on top. It occurs in the place where the bite was made by an insect carrier or an animal from the canine family, in whose body there is a causative agent of visceral leishmaniasis.

A constant symptom, which is first of all worth paying attention to, is an enlargement of the spleen and liver. It is the spleen that grows very rapidly and after a couple of months after infection, it can occupy the entire left side of the peritoneum. To the touch, the organs become dense, but there is no pain. The liver does not increase so quickly, but very serious disturbances in functions can be observed in it, up to ascites.

If the bone marrow is affected by the disease, then the signs are manifested by thrombocytopenia and agranulocytosis, which may be accompanied by angina. The first thing that can be seen on the human body is the rapid appearance of colored pigment spots.

Cutaneous form of leishmaniasis

Very common and has several forms, one of them is cutaneous leishmaniasis. Reproduction of the pathogen occurs in the tissues of the human body, where Leishmania mature very quickly and turn into flagellated larvae. This is called the primary focus of the disease, and a granuloma is formed. It consists of epithelial and plasma cells, macrophages and lymphocytes. Decay products can cause significant inflammatory changes that can reach lymphangitis or lymphadenitis.

Symptoms of the skin form

The duration of the incubation period of the cutaneous form of leishmaniasis is about one and a half months. There are several main stages of the disease:

1. The appearance of a tubercle on the skin and its rapid increase. Its dimensions are within 2 cm.
2. The ulcer appears after a few days. First, it is covered with a thin crust, which later disappears, and a soft pink bottom with weeping appears on the surface, later an abscess forms. The edges of the ulcer are slightly raised and loose.
3. Scar. After a couple of days, the bottom of the ulcer is completely cleared and covered with granulations, in the future it all scars.

The main signs of the skin form

There is not only a rural form, but also an urban one, and they differ little from each other, but it must be remembered that there are several basic features that make it possible to distinguish them.

The main and very important circumstance is the correct and careful collection of anamnesis. Long stay in an urban or rural environment will indicate in favor of one of the forms of the disease. The rural type always proceeds in the primary form, but the urban type can take all of the existing types.

mucocutaneous form of the disease

In addition to the forms of the disease described above, there is another fairly common and very dangerous one - this is mucocutaneous leishmaniasis (espundia). Its pathogens are mosquitoes.

From an insect bite to the first signs of the disease, it can take about 3 months. In the place where a person was bitten by a mosquito, a deep ulcer forms. It involves the mucosa, lymphatic system and blood vessels. All this leads to very complex and severe complications, while the prognosis is not encouraging.

Human leishmaniasis in any of the existing forms is very dangerous, as it affects internal organs that are poorly treated, such as the spleen and liver. It is for this reason that doctors recommend going to the hospital at the first ailment; in the early stages of the disease, you can quickly recover with minimal consequences.

Other types of leishmaniasis disease

We have already described several main forms of such an ailment as leishmaniasis, but there are several more of its types, perhaps not so common, but also dangerous to humans:

1. Sequential leishmanioma - the presence of a primary form with the addition of secondary signs in the form of small nodules.
2. Tuberculoid leishmaniasis. Photos of patients prove that the signs of the disease appear at the site of the primary form or at the site of the scar. In this case, the primary defect causes the presence of a small tubercle of pale yellow color no larger than the head of a pin.
3. Diffuse leishmaniasis. This form of the disease most often occurs in people with a low level of immunity and is characterized by extensive ulcerative lesions of the skin and a chronic process.

What is leishmaniasis, we figured out, and how to properly diagnose it, we will tell further.

Varieties of diagnosis of leishmaniasis

The clinical diagnosis of a patient with leishmaniasis is made on the basis of epidemiological data and the clinical picture. Laboratory diagnostics will help to accurately confirm the presence of the disease. Leishmaniasis is detected by the following methods:

• Research on bacteria: they take a scraping from an ulcer and a tubercle.
• Microscopic examination: a smear or a thick drop is taken from the patient. This method can detect the presence of Leishmania stained according to Romanovsky-Giemsa.

• A biopsy of the liver and spleen is performed, in the most severe cases, a bone marrow punctate is made.
• Serological methods such as RSK, ELISA and others.

There are a huge number of methods for accurately determining, and each of them will show the most accurate data and indicate the presence in the human body of a disease such as leishmaniasis. Diagnosis in a short time will determine the severity of the disease.

Treatment

What is leishmaniasis, and how to properly diagnose it, we have already described. Now let's talk a little about how his treatment is carried out.

In the visceral form, pentavalent antimony preparations are used:

1. "Pentostam". It is administered to the patient intravenously, previously diluted in a 5% glucose solution. The drug can also be used intramuscularly. The course of treatment lasts for a month.
2. "Glucantim". The drug is used in the same way as Pentostam. If the disease is of a complex form, then the dose can be increased and the course of treatment extended for another month, but this can only be done with the permission of the attending physician.
3. "Solyusurmin". The drug can be administered intravenously or intramuscularly, treatment should begin with 0.02 g per kg of body weight. Gradually, over 20 days, the dose is increased to 1.6 g / kg.

Also, with a very severe form of the disease, excellent results are obtained by treatment with the drug "Amphotericin B". The initial dose is 0.1 mg/kg. Gradually, it increases, but not more than 2 g per day. The drug is administered intravenously, previously it is dissolved in a glucose solution.

In the most difficult cases, when all the drugs have been used and have not brought the desired results, surgical intervention is prescribed - splenectomy. After such an operation, the patient returns to normal very quickly, but there is only a risk of developing other infectious diseases.

With the skin form of the disease, you can use all the drugs described by us above, and additionally prescribe warming and UVI.

Consequences of leishmaniasis

The prognosis and outcome of treatment after an infectious disease such as leishmaniasis is ambiguous. Despite the fact that the visceral form proceeds with great complications, and it is very dangerous for the patient's life, with timely treatment, the disease passes without a trace and does not cause much harm to the body.

As a result of the cutaneous form, especially its diffuse variant, scars and scars may remain on the skin. And in some, rather complex cases, changes in the bone skeleton can even occur.

Possible Complications

Possible complications after the disease leishmaniasis (photos of patients with this disease can be seen in our article). The later the disease is detected and the treatment process is started, the higher the risk of severe complications. With leishmaniasis, they can take the following form:

• Liver failure aggravated by ascites and cirrhosis.
• Severe anemia and DIC.
• Amyloidosis of the kidneys.
• Ulcers on the mucosa of the digestive tract.

In the cutaneous form of the disease, complications are mainly associated with the addition of a secondary infection. It manifests itself as phlegmon and local abscesses, but in the absence of properly selected treatment, it can develop into a severe septic form.

What is leishmaniasis? This is a very serious infectious disease that has different forms, each of which is quite dangerous for humans. But there are several methods of prevention that will help to avoid the disease or prevent its severe form.

Disease prevention

The general principle for the prevention of leishmaniasis is protective measures. We must try to protect ourselves from the bites of mosquitoes, which are carriers of the disease. Regular disinfection and rodent control should be carried out, and domestic animals of the canine family that were taken from the forest should be kept away from themselves.

And drug prophylaxis will only help in protecting against the skin form of the disease. So, a person who goes to endemic areas is vaccinated.

Leishmaniasis is a fairly serious disease, about half a million people die from it every year, so you should treat it with full responsibility and run to the doctor at the first sign. Only the early stages of the disease can be cured without further consequences.

But it’s so established in our country that all “forgotten diseases” are not funded, so no one will vaccinate the population until the person himself buys the vaccine and asks for it. This is how it turns out that the disease is very well-known, and there is simply not enough money for the correct treatment. Therefore, it is better to do everything possible on your own to prevent infection.

Localization. Cells of the liver, spleen, bone marrow, lymph nodes, reticuloendothelial cells of the subcutaneous tissue.

Geographic distribution. Visceral leishmaniasis is most common in India (pathogen L. donovani), occurs in the Mediterranean countries, in Transcaucasia and Central Asia (pathogen L. infantum), where it is called kala-azar. In a number of countries in Asia, Africa and South America, leishmaniasis is also caused by other types of leishmania.

Morphophysiological characteristics. Leptomonad and Leishmanial forms.

Recently, Leishmania has also been found to reside in the reticuloendothelial cells of the skin, which explains the mode of infection of mosquitoes. Affected cells sometimes form a continuous layer or are concentrated near the sweat glands and vessels.

Pathogenic action. There is irregular, persistent fever. The spleen and liver gradually increase and can reach enormous sizes (Fig. 3). Exhaustion develops, the content of erythrocytes in the blood decreases, anemia occurs. The disease can be acute or take a chronic course (1-3 years). Mortality is very high. Mostly children are ill.

Prevention: personal - individual protection against mosquito bites; public - a set of measures to combat mosquitoes and rodents, the destruction of stray and leishmaniasis dogs, jackals. At the same time, it is necessary to carry out sanitary-educational work and treatment of patients.

As mentioned above, the carrier of the pathogen are female mosquitoes. During a bite, from 100 to 1000 pathogens enter the human body along with saliva. Leishmania have a specific ability - they freely penetrate macrophages without provoking an immune response. In them, they are transformed into an intracellular form and begin to actively multiply, provoking pathological reactions from the internal organs of a person.

The disease can be transmitted directly from a carrier to a person, as well as from a person to a mosquito (in this case, they speak of the progression of anthroponotic leishmaniasis). It should be noted that the disease is characterized by seasonality. Most often it is diagnosed in the period from May to November. Such time frames are due to the vital activity of mosquitoes.

Classification

Clinicians distinguish two forms of the disease, different in their course, as well as in the clinic:

The symptoms of the disease directly depend on its form, which began to progress in a person. It is important at the first signs indicating leishmaniasis to immediately contact a medical institution for diagnosis and treatment of the disease.

Clinic of visceral leishmaniasis

Due to the long incubation period, not many patients can relate the progression of visceral leishmaniasis to a mosquito bite. This, to some extent, complicates the diagnosis. The first signs of visceral leishmaniasis can appear only six months after the pathogen enters the body. The patient has the following symptoms:

• malaise;
• lethargy;
• fast fatiguability;
• weakness;
• loss of appetite;
• hyperthermia up to 40 degrees;
• there is a change in the color of the skin. It acquires a grayish tint, and in some cases hemorrhages appear on it;
• insignificant . At the same time, they are not painful and do not get drunk among themselves.

The first sign of the progression of visceral leishmaniasis is the appearance on the skin of a hyperemic papule, covered with scales on top (occurs at the site of the bite).

A characteristic and constant symptom of pathology is. It is the spleen that increases in size more rapidly. Already in the first month, its size can be so large that the organ will occupy the entire left side of the abdomen. As visceral leishmaniasis progresses, both organs become dense, but pain does not occur when palpated. An enlarged liver is fraught with dangerous consequences, up to and.

Clinic for cutaneous leishmaniasis

The incubation period for cutaneous leishmaniasis ranges from 10 days to 1–1.5 months. More often, the first symptoms of pathology appear in humans on the 15-20th day. Symptoms may vary somewhat depending on which form of cutaneous leishmaniasis progresses in the patient. In total there are five forms of the disease:

• primary leishmanioma;
• serial leishmanioma;
• tuberculoid leishmaniasis;
• espundia;
• diffuse leishmaniasis.

Primary leishmanioma develops in three stages:

• tubercle stage. A papule forms on the skin, which grows rapidly. Sometimes its size can reach 1.5 cm;
• ulcer stage. A few days after the appearance of a specific tubercle, the upper crust falls off from it, exposing the bottom with weeping. At first, a serous exudate is released, but then it becomes purulent. A hyperemic ring is noted along the edges of the ulcer;
• scarring stage. The bottom of the ulcer clears itself a few days after its appearance, becomes covered with granulations and scars.

As sequential leishmanioma progresses, several other secondary nodules form around the primary lesion. Tuberculoid leishmaniasis manifests itself at the site of the formed primary leishmanioma or at the site of the scar from it. With the progression of this form of cutaneous leishmaniasis, a pathological tubercle is formed, which has a light yellow color. Its dimensions are small.

Espundia is a special form of cutaneous leishmaniasis. Symptoms of pathology appear gradually. Extensive ulcers appear against the background of already existing lesions of the skin. It is most often seen in the limbs. Gradually, the pathogen penetrates into the mucous membrane of the pharynx, cheeks, larynx and nose, where it provokes purulent-necrotic changes.

Diagnostics

Leishmaniasis is diagnosed by an infectious disease specialist. Clinical diagnosis is made on the basis of a characteristic clinical picture, as well as epidemiological data. To confirm the presence of cutaneous leishmaniasis or visceral, resort to the following diagnostic methods:

• tank. examination of a scraping previously taken from a tubercle or an open ulcer;
• microscopic examination of a thick drop of blood;
• biopsy of the liver and spleen;

Treatment

Treatment of visceral and cutaneous leishmaniasis is carried out in stationary conditions. The treatment plan is developed taking into account the severity of the course of the pathology, its type, as well as the characteristics of the patient's body. Doctors resort to conservative and surgical methods of treatment.

In the visceral form, the treatment plan includes such drugs:

• Pentostam;
• Glucantim;
• Solyusurmin.

The course of treatment with these drugs is from 20 to 30 days. If resistance is observed, then the dosage of the drugs is increased and the course is extended to 60 days. Also, the treatment plan is supplemented with amphotericin B.

If conservative treatment was ineffective and the patient's condition did not stabilize, then a surgical intervention is performed - the spleen is removed. With skin forms of the disease, they also resort to physiotherapy treatment - they warm up the skin and conduct UV radiation.

Prevention

In order not to carry out the treatment of pathology, it is necessary to start its prevention as early as possible. To protect yourself from mosquito bites, you must use personal insect repellent. Also, for the purpose of prevention in areas with a high risk of infection, it is necessary to disinfect residential premises and install mosquito nets on windows.

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Diseases with similar symptoms:

Carbuncle is an inflammatory disease that affects the hair follicles, sebaceous glands, as well as the skin and subcutaneous tissue. As a rule, the inflammatory process can spread to the deep layers of the dermis. Most often, purulent formations are localized in the neck, but their appearance on the buttocks or shoulder blades is also not excluded.

• What is Leishmaniasis
• What causes Leishmaniasis
• Symptoms of Leishmaniasis
• Diagnosis of Leishmaniasis
• Leishmaniasis treatment
• Prevention of Leishmaniasis
• Which doctors should you contact if you have Leishmaniasis

What is Leishmaniasis

According to the World Health Organization, leishmaniasis occurs in 88 countries of the Old and New Worlds. Of these, 72 are in developing countries, and among these, thirteen are the world's poorest countries. Visceral leishmaniasis occurs in 65 countries.

Leishmaniasis are neglected diseases.

What causes Leishmaniasis

Reservoir and sources of invasion- man and various animals. Among the latter, jackals, foxes, dogs and rodents (gerbils - large, red-tailed, midday, fine-toed ground squirrel, etc.) are of the greatest importance. Infectivity lasts an indefinitely long time and is equal to the period of stay of the pathogen in the blood and ulceration of the host's skin. The duration of cutaneous leishmaniasis in gerbils is usually about 3 months, but can be up to 7 months or more.

The main epidemiological signs of leishmaniasis. Indian visceral leishmaniasis (kala-azar) caused by L. donovani is an anthroponosis. It is distributed in a number of regions of Pakistan, Bangladesh, Nepal, China, etc. It is distinguished by outbreaks of the disease that occur from time to time. Predominantly adolescents and young people, mainly living in rural areas, are ill.

South American visceral leishmaniasis(visceral leishmaniasis of the New World), caused by L. chagasi, is close in its manifestations to the Mediterranean-Central Asian leishmaniasis. Note mainly sporadic incidence in a number of countries in Central and South America.

Anthroponotic cutaneous leishmaniasis of the Old World(Borovsky's disease), caused by L. minor, is common in the Mediterranean, the countries of the Near and Middle East, in the western part of the Hindustan peninsula, Central Asia and Transcaucasia. The disease occurs mainly in cities and urban-type settlements where mosquitoes live. Among the local population, children are more likely to get sick, among visitors - people of all ages. Summer-autumn seasonality is characteristic, which is associated with the activity of carriers.

Zoonotic cutaneous leishmaniasis of the Old World(pendinskaya ulcer) is caused by L. major. The main reservoir of invasion is rodents (large and red gerbil, etc.). Distributed in the countries of the Middle East, North and West Africa, Asia, Turkmenistan and Uzbekistan. Endemic foci are found mainly in the desert and semi-desert, in rural areas and on the outskirts of cities. Summer seasonality of infections is determined by the period of activity of mosquitoes. Children are predominantly ill; among visitors, outbreaks of diseases among people of different ages are possible.

New World zoonotic cutaneous leishmaniasis(Mexican, Brazilian and Peruvian cutaneous leishmaniasis) caused by L. mexicana, L. braziliensis, L. peruviana, L. uta, L. amazoniensis, L. pifanoi, L. venezuelensis, L. garnhami, L. panamensis, are registered in the Central and South America, as well as in the southern regions of the United States. The natural reservoir of pathogens is rodents, numerous wild and domestic animals. Diseases are found in rural areas, mainly during the rainy season. People of all ages get sick. Usually infection occurs at the time of work in the forest, hunting, etc.

Pathogenesis (what happens?) during Leishmaniasis

When bitten by mosquitoes, Leishmania in the form of promastigotes penetrate the human body. Their primary reproduction in macrophages is accompanied by the transformation of pathogens into amastigotes (a non-flagellated form). At the same time, productive inflammation develops, and a specific granuloma is formed at the site of implementation. It consists of macrophages containing pathogens, reticular, epithelioid and giant cells. The primary affect is formed in the form of a papule; in the future, with visceral leishmaniasis, it resolves without a trace or scars.

With cutaneous leishmaniasis, destruction of the skin in the place of the former tubercle develops, ulceration and then healing of the ulcer with the formation of a scar. Spreading through the lymphogenous route to the regional lymph nodes, leishmania provoke the development of lymphangitis and lymphadenitis, the formation of limited skin lesions in the form of successive leishmania. The development of tuberculoid or diffusely infiltrating cutaneous leishmaniasis is largely due to the state of the body's reactivity (respectively, hyperergy or hypoergy).

Along with skin forms of the disease, so-called mucocutaneous forms with ulceration of the mucous membranes of the nasopharynx, larynx, trachea and subsequent formation of polyps or deep destruction of soft tissues and cartilage can be observed. These forms are registered in the countries of South America.

Convalescents develop persistent homologous immunity.

Symptoms of Leishmaniasis

In accordance with the characteristics of the clinic, etiology and epidemiology, leishmaniasis is divided into the following types.

Visceral leishmaniasis (kala-azar)
1. Zoonotic: Mediterranean-Central Asian (children's kala-azar), East African (dum-dum fever), mucocutaneous leishmaniasis (New World leishmaniasis, nasopharyngeal leishmaniasis).
2. Anthroponous (Indian kala-azar).

Cutaneous leishmaniasis
1. Zoonotic (rural type of Borovsky's disease, Pendin's ulcer).
2. Anthroponotic (urban type of Borovsky's disease, Ashgabat ulcer, Baghdad furuncle).
3. Cutaneous and mucocutaneous leishmaniasis of the New World (espundia, Breda's disease).
4. Ethiopian cutaneous leishmaniasis.

Visceral Mediterranean-Asian leishmaniasis.
incubation period. It varies from 20 days to 3-5 months, in rare cases up to 1 year or more. In young children and rarely in adults, long before the general manifestations of the disease, a primary affect occurs in the form of a papule.

The initial period of the disease. Characterized by the gradual development of weakness, loss of appetite, weakness, pallor of the skin, a slight increase in the spleen. The body temperature rises slightly.

Height period. Usually begins with a rise in body temperature to 39-40 ° C. The fever takes on an undulating or irregular character and lasts from several days to several months, with episodes of high fever and remissions. In some cases, body temperature during the first 2-3 months is subfebrile or even normal.

When examining patients, polylymphadenopathy (peripheral, peribronchial, mesenteric and other lymph nodes), enlargement and thickening of the liver and even more of the spleen, which are painless on palpation, are determined. In cases of development of bronchodenitis, a cough is possible, pneumonia of a secondary bacterial nature is not uncommon.

As the disease progresses, the condition of patients progressively worsens. Weight loss develops (up to cachexia), hypersplenism. Bone marrow lesions lead to progressive anemia, granulocytopenia, and agranulocytosis, sometimes with necrosis of the oral mucosa. Often there are manifestations of hemorrhagic syndrome: hemorrhages in the skin and mucous membranes, bleeding from the nose, gastrointestinal tract. Fibrotic changes in the liver lead to portal hypertension with edema and ascites, which is facilitated by progressive hypoalbuminemia.

Due to hypersplenism and high standing of the diaphragm, the heart shifts somewhat to the right, its tones become muffled, tachycardia and arterial hypotension develop. These changes, along with anemia and intoxication, lead to the appearance and growth of signs of heart failure. Diarrhea, menstrual disorders, impotence are possible.

terminal period. Cachexia, a drop in muscle tone, thinning of the skin, the development of protein-free edema, severe anemia are observed.

The disease can manifest itself in acute, subacute and chronic forms.
Sharp form. Rarely seen in young children. It develops rapidly, without treatment quickly ends in death.
Subacute form. Meet more often. Severe clinical manifestations lasting 5-6 months are characteristic.
Chronic form. It develops most often, often proceeds subclinically and latently.

With visceral anthroponotic leishmaniasis (Indian kala-azar), in 10% of patients, so-called leishmanoids appear on the skin a few months (up to 1 year) after therapeutic remission. They are small nodules, papillomas, erythematous patches or areas of skin with reduced pigmentation, which contain Leishmania for a long time (years and decades).

Cutaneous zoonotic leishmaniasis(pendinskaya ulcer, Borovsky's disease). Found in tropical and subtropical countries. The incubation period varies from 1 week to 1.5 months, averaging 10-20 days. Primary leishmanioma appears at the site of the entrance gate, initially representing a smooth pink papule with a diameter of 2-3 mm. The size of the tubercle increases rapidly, while it sometimes resembles a boil, but painless or slightly painful on palpation. After 1-2 weeks, necrosis begins in the center of the leishmanioma, resembling the head of an abscess, and then a painful ulcer is formed up to 1-1.5 cm in diameter, with undermined edges, a powerful infiltrate rim and abundant serous-purulent or sanious exudate; Small secondary tubercles often form around it, the so-called "tubercles of seeding", which also ulcerate and, when merged, form ulcerative fields. This is how a sequential leishmanioma is formed. Leishmaniomas are more often localized on open parts of the body, their number varies from units to tens. The formation of ulcers in many cases accompanies the development of painless lymphangitis and lymphadenitis. After 2-6 months, epithelialization of ulcers and their scarring begin. The total duration of the disease does not exceed 6-7 months.

Diffuse infiltrating leishmaniasis. It is characterized by pronounced infiltration and thickening of the skin with a large distribution area. Gradually, the infiltrate resolves without a trace. Small ulcerations are observed only in exceptional cases; they heal with the formation of barely noticeable scars. This variant of cutaneous leishmaniasis is very rare in the elderly.

Tuberculoid cutaneous leishmaniasis. Sometimes observed in children and young people. It is distinguished by the formation of small tubercles around the scars or on them. The latter can increase and merge with each other. In the dynamics of the disease, they occasionally ulcerate; subsequently ulcers heal with scarring.

Cutaneous anptroponous leishmaniasis. It is distinguished by a long incubation period of several months or even years and two main features: slow development and less pronounced skin lesions.

Complications and prognosis
Running leishmaniasis can be complicated by pneumonia, purulent-necrotic processes, nephritis, agranulocytosis, hemorrhagic diathesis. The prognosis of severe and complicated forms of visceral leishmaniasis with untimely treatment is often unfavorable. In mild forms, spontaneous recovery is possible. In cases of cutaneous leishmaniasis, the prognosis for life is favorable, but cosmetic defects are possible.

Diagnosis of Leishmaniasis

Visceral leishmaniasis should be distinguished from malaria, typhoid-paratyphoid diseases, brucellosis, lymphogranulomatosis, leukemia, sepsis. When establishing a diagnosis, epidemiological anamnesis data are used, indicating the patient's stay in endemic foci of the disease. When examining a patient, it is necessary to pay attention to prolonged fever, polylymphadenopathy, anemia, weight loss, hepatolienal syndrome with a significant increase in the spleen.

Manifestations of cutaneous zoonotic leishmaniasis are differentiated from similar local changes in leprosy, skin tuberculosis, syphilis, tropical ulcers, and epithelioma. In this case, it is necessary to take into account the phase nature of the formation of leishmanioma (painless papule - necrotic changes - an ulcer with undermined edges, a rim of infiltrate and serous-purulent exudate - scar formation).

Laboratory diagnosis of leishmaniasis
In the hemogram, signs of hypochromic anemia, leukopenia, neutropenia and relative lymphocytosis, aneosinophilia, thrombocytopenia, and a significant increase in ESR are determined. Poikilocytosis, anisocytosis, anisochromia are characteristic, agranulocytosis is possible. Hypergammaglobulinemia is noted.

With cutaneous leishmaniasis, pathogens can be detected in material obtained from tubercles or ulcers, with visceral - in smears and thick drops of blood stained according to Romanovsky-Giemsa, much more often (95% of positive results) - in smears of bone marrow punctates. The culture of the pathogen (promastigotes) can be obtained by inoculation of punctate on NNN medium. Sometimes, to detect Leishmania, a biopsy of the lymph nodes and even the liver and spleen is performed. Serological reactions are widely used - RSK, ELISA, RNIF, RLA, etc., biological tests on hamsters or white mice. During the period of convalescence, a skin test with leishmanin (Montenegro reaction), which is used only in epidemiological studies, becomes positive.

Leishmaniasis treatment

In visceral leishmaniasis, pentavalent antimony preparations (solusurmin, neostibosan, glucantim, etc.) are used in the form of daily intravenous infusions in increasing doses starting from 0.05 g / kg. The course of treatment is 7-10 days. With insufficient clinical efficacy of drugs, amphotericin B is prescribed at 0.25-1 mg / kg slowly intravenously in a 5% glucose solution; the drug is administered every other day for up to 8 weeks. Pathogenetic therapy and prevention of bacterial complications are carried out according to well-known schemes.

In cases of cutaneous leishmaniasis at an early stage of the disease, tubercles are chipped with solutions of mepacrine, monomycin, urotropine, berberine sulfate; apply ointments and lotions using these funds. With ulcers formed, intramuscular injections of monomycin are prescribed at 250 thousand units (for children 4-5 thousand units / kg) 3 times a day, the course dose of the drug is 10 million units. You can treat with aminoquinol (0.2 g 3 times a day, per course - 11-12 g of the drug). Apply laser irradiation of ulcers. Pentavalent antimony drugs and amphotericin B are prescribed only in severe cases of the disease.

Drugs of choice: antimonil sodium gluconate 20 mg/kg intravenously or intramuscularly once a day for 20-30 days; meglumine antimoniate (glucantim) 20-60 mg/kg deep intramuscularly once a day for 20-30 days. In case of recurrence of the disease or insufficient effectiveness of treatment, a second course of injections should be carried out within 40-60 days. An additional appointment of allopurinol at 20-30 mg/kg/day in 3 oral doses is effective.

Alternative drugs for relapses of the disease and resistance of the pathogen: amphotericin B at 0.5-1.0 mg/kg IV every other day or pentamidine IM 3-4 mg/kg 3 times a week for 5-25 weeks. In the absence of the effect of chemotherapy, human recombinant y-interferon is additionally prescribed.

Surgery. According to the indications, a splenectomy is performed.

Prevention of Leishmaniasis

The fight against animal carriers of leishmania is carried out in an organized and large-scale manner only with zoonotic cutaneous and visceral leishmaniasis. They carry out deratization measures, landscaping of populated areas, elimination of wastelands and dumps in them, drainage of basements, treatment of residential, household and livestock premises with insecticides. The use of repellents, mechanical means of protection against mosquito bites is recommended.

After identifying and treating sick people, the source of invasion is neutralized. In small groups, chemoprophylaxis is carried out by prescribing chloridine (pyrimethamine) during the epidemic season. Immunoprophylaxis of zoonotic cutaneous leishmaniasis is carried out with a live culture of promastigotes of the virulent strain L. major during the inter-epidemic period among persons traveling to endemic foci, or non-immune persons living in these foci. 04/25/2019

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Visceral leishmaniasis (synonym: anaemia splenica infantum, internal leishmaniasis, childhood leishmaniasis, kala-azar) is one of the vector-borne tropical diseases and occurs between 45 ° N. sh. and 30°S sh. According to the epidemiological and clinical features, the disease is divided into two main forms (each with its own geographical variants): kala-azar, found in the tropics and humid subtropics, and Mediterranean visceral leishmaniasis, found in the subtropics with moderate humidity and in countries with a temperate and continental climate. (hot and dry summer).

E epidemiology. Kala-azar is an anthroponosis; its causative agent - Leishmania donovani Laveran et Mesni], 1903, carriers - mosquitoes from the subgenus Laroussius, in India - Ph. argentipes, in East China - Ph. chinensis, in Sudan - Ph. orientalis. This form of the disease is characterized by epidemic outbreaks involving all or several family members. Children and adults are ill, mainly up to 30 years.

Mediterranean visceral leishmaniasis is a zoonosis. Dogs are considered the main reservoir of the pathogen (L. donovani infantum Nico-11e, 1908); natural focality has been established in a number of places, in some countries small epidemic outbreaks are occasionally observed. Children of younger age are ill more often. Depending on the ecological conditions of the foci of the disease, various types of mosquitoes, mainly from the subgenus Laroussius, are carriers.

Immunity. In visceral leishmaniasis, there appears to be both natural and acquired immunity. Recurrences are not noted. Munson-Bar (R. E. C. Manson-Bahr) proposed an intradermal leishmanin test, which, like tuberculin, consists in the intradermal injection of 0.1-0.2 ml of an antigen containing 6-10 million killed leptomonas from a culture grown on the NNN environment (Ncolle, Novy, Mac Neal). Hardening of this area of ​​skin after 72 hours indicates a positive reaction. This test becomes positive after 1-2 months. after a full course of treatment of patients with kala-azar.

Clinical picture (symptoms and signs). The incubation period lasts from 20 days to 10 months. and more, more often 3-5 months. The temperature rises gradually and very rarely suddenly after a chill. A wavy (undulating) type of temperature curve is characteristic (Fig. 3). When measuring temperature every two hours, fluctuations during the day are often noticed. The skin acquires a peculiar color, in India - dark, almost black (kala-azar - black disease). Dark staining of the skin is explained by the hypofunction of the adrenal glands, which is associated with the presence of Leishmania in the macrophages of the cortical part of these glands. The mucous membranes are usually pale. In advanced cases, edema is observed, often of the lower extremities, sometimes of the eyelids, face and entire body, which are dystrophic in nature. Patients lose weight, cachexia sometimes develops. The abdomen due to the spleen and liver is enlarged ("frog" appearance). Lymph nodes are enlarged, periadenitis is not observed. In advanced cases, a cardiac impulse is observed in the IV (rarely III) intercostal space, 0.5-2 cm outward from the left nipple line due to an increase in the upper borders of the spleen, liver and high standing of the diaphragm.

Heart sounds are usually muffled. With severe anemia above the heart, murmurs due to anemia are heard. Relative tachycardia is characteristic both during fever and during remission. On the ECG in children, a high T wave is noted, especially in leads I and II (Fig. 4), indicating the presence of transient myocardial dystrophy. A decrease in blood pressure is characteristic. On the part of the respiratory organs, tachypnea, inflammatory complications due to secondary, mainly coccal, infection (bronchitis and bronchopneumonia) are observed.

Inflammatory-purulent processes can capture the organs of hearing (most often purulent otitis media), as well as the pharynx, gums, tongue, etc.

The splenohepatic syndrome is expressed in all patients, but with varying intensity. With leishmania splenomegaly, the spleen is somewhat elastic, its surface is smooth, 1-4 notches are noticeable on the medial edge. There are violations of the intestines (enteritis - more often, enterocolitis and colitis - less often). The recovery period is characterized by bulimia. In advanced cases, hypostenuria is not uncommon.

On the part of the nervous system, functional disorders such as neurasthenia and vegetative dystonia are noted.

The presence of anemia, leukopenia with a tendency to agranulocytosis is characteristic, and these phenomena are more pronounced when the disease is 2 months old. and more. In the bone marrow punctate - the so-called bodies of Botkin - Gumprecht, proerythroblasts, erythrocytes with basophilic granularity and fragments of the cytoplasm of endothelial cells, often containing leishmania (there are more of the latter in the splenic punctate than in the bone marrow). The appearance of these elements, especially fragments of the cytoplasm of endothelial cells, in the peripheral blood significantly worsens the prognosis.

In the peripheral blood - aneosinophilia or eosinopenia, neutropenia with a shift to the left, sometimes to myelocytes, lymphocytosis and often monocytosis. The absolute number of these elements is below the norm. There is thrombopenia. ROE is accelerated (for example, up to 92 mm), especially in the first 15 minutes. The most severe expression of agranulocytosis (see) is the symptom complex of agranulocytic tonsillitis. At the same time, in the oral cavity on the tonsils, the mucous membrane of the cheeks, and sometimes the gums, necrotic and gangrenous processes are observed with severe leukopenia and complete agranulocytosis. In the bone marrow - a myeloid reaction with the phenomena of inhibition of eosinophilo- and megakaryocytopoiesis.

With kala-azar, leishmania in the peripheral blood is often found, with the Mediterranean form - very rarely.

From laboratory diagnostic methods, serological reactions are used: formol, antimony and with distilled water.

Napier formol reaction technician. To 1 ml of blood serum placed in an agglutination tube, add a drop of 40% formalin solution; with a disease duration of 3-4 months. and more after 1-2 minutes. The mixture hardens, and after 3-20 minutes. completely coagulates and takes the form of a hard-boiled egg protein. Chopra antimony reaction technique. The blood serum is mixed with physiological saline solution 1: 10; to 1 ml of this mixture add 1 ml of a 4% solution of solyusuryin or another freshly prepared antimony preparation; in positive cases, turbidity appears, and then a white precipitate. Bramahari Distilled Water Reaction Technique. 1 ml of serum is poured into distilled water (2 ml); in positive cases, turbidity and sediment form. These reactions become positive in patients with a disease duration of at least 2 months. RSCs are not entirely reliable. For the diagnosis and prognosis, it is important to take into account neutrophils with toxogenic granularity in blood and bone marrow smears stained according to E. I. Freifeld.

Forecast. Severe diseases without specific treatment usually end in death. With proper treatment of unopened cases, it is possible to achieve a cure for almost all patients; in some cases, the disease takes an abortive course and ends with a spontaneous cure.

Treatment. Apply solyusurmin (sodium salt of a complex compound of pentavalent antimony and gluconic acid), containing 21-23% antimony. The drug is administered subcutaneously or intravenously in the form of freshly prepared 5-10-20% aqueous solutions in double-distilled water; sterilized at t° 100° no more than 30 min.

Injections of the drug are made daily, 1 time per day. The course of treatment consists of 15-30 injections, rarely more. Depending on tolerance, the drug is prescribed at the rate of 0.05-0.15 g per 1 kg of body weight.

In the first injection - 1/3 of the dose, in the second - 2/3 and in the third injection - the full dose. In case of poor tolerance, a 1-2-day break is taken and the dose is reduced, and then it is increased again.

With concomitant inflammatory processes, antibacterial drugs (sulfonamides, antibiotics) are used. Along with specific treatment, symptomatic agents are used (calcium chloride, vitamins, antianemic drugs, general tonic and stimulants, etc.).

Indicators of cure - improvement in the general condition of patients, the disappearance of leishmania in the bone marrow, a decrease in ESR, a sharp decrease in the size of the spleen and liver. An important criterion for a relapse-free cure should be considered the normalization of the leukocyte blood picture, a steady rise in the absolute number of neutrophils to the age norm. In the period of convalescence, a transient phase of eosinophilia up to 20%, a sharp decrease in neutrophils with toxogenic granularity, and the complete disappearance of coarse granularity both in the peripheral blood and in the bone marrow are observed.

Cala-azar and its geographical variants are much easier to treat with antimony and diamidines. After treatment, cutaneous leishmanoids appear on the skin.

The Mediterranean form is resistant to these drugs.

Prevention. The complex of preventive measures includes measures aimed at combating vectors, protecting the population from their attacks, actively identifying patients in the early phases of the disease and treating them, and exterminating animals carrying Leishmania.