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 ubject: PRO/AH/EDR> Leishmaniasis - USA: new guidelines, IDSA
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LEISHMANIASIS - USA: NEW GUIDELINES, INFECTIOUS DISEASES SOCIETY OF
AMERICA
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A ProMED-mail post
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International Society for Infectious Diseases
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Date: Tue 15 Nov 2016
Source: Infectious Diseases Society of America (IDSA) press release
[edited]
<http://www.idsociety.org/Press_Release_11_15_2016/>

Driven by burgeoning ecotourism and military campaigns in Iraq and
Afghanistan, a parasitic infection called leishmaniasis is showing up
in more US patients, often stumping doctors. Rapid diagnostic tests
and innovative treatments are among the strategies to address
leishmaniasis highlighted in new guidelines released by the Infectious
Diseases Society of America (IDSA) and the American Society of
Tropical Medicine and Hygiene (ASTMH) and published in the journal
Clinical Infectious Diseases [see reference below].

The bite of the nearly invisible sand fly - 1/3 the size of a
mosquito - transmits the leishmania parasite. The parasite is found
in more than 90 countries around the world - including Mexico and
those in Central and South America, Asia, Africa, the Middle East, and
southern Europe.

The infection rarely occurs in the United States, although a few cases
have been reported to have been acquired in Texas and Oklahoma. The
growth of travelers, soldiers, and immigrants with leishmaniasis being
seen by US doctors and the complicated diagnosis and management of the
disease drove the creation of these guidelines, the 1st in the United
States.

"Leishmaniasis is an increasingly common infection in ecotourists
traveling to Central and South America. Travelers visiting the jungle
in the Amazon basin have a high likelihood of being exposed," said
Naomi E Aronson, MD, lead author of the guidelines. "The cutaneous and
mucosal forms of the infection cause serious scarring and visceral
leishmaniasis can be deadly, so timely diagnosis and treatment managed
by an infectious diseases physician is vital. Because it's still
relatively uncommon in the United States, many doctors are unfamiliar
with leishmaniasis and don't suspect it when diagnosing patients.

The sore at the site of an infected sand fly bite often is painless
and symptoms of the infection may not show up for a month or longer,
further complicating the diagnosis. More than 20 types of leishmania
parasites cause human infection.

The 3 main clinical syndromes, often determined by the specific
parasite, are:
- cutaneous leishmaniasis (CL): CL causes skin sores, such as bumps or
lumps that may turn into ulcers with a central crater or scab over.
This is the commonest type of leishmaniasis, with an estimated 700 000
to 1.2 million cases worldwide every year, according to the Centers
for Disease Control and Prevention (CDC).
- mucosal leishmaniasis (ML): CL can metastasize, or spread, to mucous
membranes, especially the mouth and nose, resulting in ML. ML most
often occurs when the patient is infected by leishmania parasites from
Central or South America. Untreated, ML can cause serious scarring and
deformity.
- visceral leishmaniasis (VL): the most serious form, active VL is a
systemic infection that is almost always fatal if not treated.
Symptoms include weeks to months of high fevers, significant weight
loss, an enlarged spleen and low blood counts. CDC estimates there are
200 000 to 400 000 new cases of VL a year.

When doctors see infections with these symptoms, they should ask if
the patient has traveled outside of North America, Dr Aronson notes.

CL can be tested by polymerase chain reaction (PCR) or by doing a
culture to identify the type of leishmania and determine how
aggressively it should be treated. A blood test called rK39 provides a
rapid result if VL is suspected, which would be confirmed with PCR or
culture.

Oral miltefosine was approved by the Food and Drug Administration
(FDA) in 2014 for specific cases of cutaneous, mucosal, and visceral
leishmaniasis. "It may become a game-changer for treating
leishmaniasis as it is a pill that can be used for all 3 leishmaniasis
syndromes, depending on the parasite species responsible for the
infection," said Dr Aronson.

In addition, the ThermoMed(TM) [heat therapy] device can be used to
heat treat CL. FDA-approved liposomal amphotericin B is given
intravenously (IV) for VL. While more than 80 per cent effective,
these therapies don't always eradicate the parasite, and sometimes
additional treatment is necessary.

Despite the name, the fly that transmits the parasite also lives in
rotting vegetation in jungle areas. The sand fly most often bites
exposed skin at night, transmitting the parasite. While there are no
vaccines or preventive medications for leishmaniasis, people traveling
to areas where the parasite exists should use protective measures to
avoid infection. That includes wearing protective clothing (long
sleeves and pants), applying insect repellents containing DEET, and
using insecticide-impregnated bed nets.

[Reference
Aronson N, Herwaldt BL, Libman M, et al. Diagnosis and treatment of
leishmaniasis: clinical practice guidelines by the Infectious Diseases
Society of America (IDSA) and the American Society of Tropical
Medicine and Hygiene (ASTMH). Clin Infect Dis. 2016; doi:
10.1093/cid/ciw670. First published online 14 Nov 2016; available at
<http://cid.oxfordjournals.org/content/early/2016/11/03/cid.ciw670.full>]

--
communicated by:
ProMED-mail
<promed at promedmail.org>

[ProMED-mail posts extensively on leishmaniasis worldwide (see
postings in 2016 listed below). It is also important to inform
physicians that immunocompromised patients, for instance those
receiving TNF-inhibitors or being HIV positive, do often not respond
to standard treatment.

A country specific recent review of leishmaniasis was published by J
Alvar and colleagues in 2012 (Alvar J, Vélez ID, Bern C, et al. WHO
Leishmaniasis Control Team: Leishmaniasis worldwide and global
estimates of its incidence. PLoS One. 2012; 7(5): e35671. doi:
10.1371/journal.pone.0035671;
<http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0035671>).
- Mod.EP

A HealthMap/ProMED-mail map can be accessed at:
<http://healthmap.org/promed/p/106>.]

[See Also:
Leishmaniasis - Brazil (02): new sandfly vect susp, Psathyromyia
elizabethdorvalae http://promedmail.org/post/20161101.4600154
Leishmaniasis, visceral - Brazil: (MG) children
http://promedmail.org/post/20161029.4593491
Leishmaniasis, visceral - Nepal: (MO)
http://promedmail.org/post/20161002.4531103
Leishmaniasis, visceral - South Sudan: (UN)
http://promedmail.org/post/20160910.4479134
Leishmaniasis, cutaneous - Syria (03): (HL)
http://promedmail.org/post/20160821.4430681
Leishmaniasis, cutaneous - Pakistan (05): (TA)
http://promedmail.org/post/20160717.4350532
Leishmaniasis, cutaneous - Syria (02)
http://promedmail.org/post/20160630.4319680
Leishmaniasis, cutaneous - Syria: refugees
http://promedmail.org/post/20160529.4252805
Leishmaniasis, cutaneous - Palestinian Auth: (WE)
http://promedmail.org/post/20160528.4250881
Leishmaniasis, cutaneous - Pakistan (04): (NW) EpiCore responses
http://promedmail.org/post/20160521.4236192
Leishmaniasis, cutaneous - Pakistan (03): (NW)
http://promedmail.org/post/20160518.4230112
Leishmaniasis, cutaneous - Colombia: (NS) alert
http://promedmail.org/post/20160429.4192208
Leishmaniasis, cutaneous - Pakistan: (02): (NW)
http://promedmail.org/post/20160418.4167556
Leishmaniasis, cutaneous - Iraq: (DA) Yazidi refugees
http://promedmail.org/post/20160415.4161067
Leishmaniasis, cutaneous - Libya: (TR)
http://promedmail.org/post/20160414.4160311
Leishmaniasis - Colombia: (TO) RFI
http://promedmail.org/post/20160403.4136205
Leishmaniasis, canine - France
http://promedmail.org/post/20160220.4033101
Leishmaniasis, cutaneous - Pakistan: (TA)
http://promedmail.org/post/20160217.4027519
Leishmaniasis - Albania, Jordan, Pakistan: surveillance 2015
http://promedmail.org/post/20160210.4009452
Leishmaniasis - Uruguay: (SA) canine, alert
http://promedmail.org/post/20160122.3952222]
.................................................sb/ep/mj/sh
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