Study of an outbreak of cutaneous leishmaniasis in Venezuela. The role of domestic animals

During an outbreak of cutaneous leishmaniasis in a locality (Las Rosas, Cojedes State, Venezuela) previously non-endemic, 12.9% of humans, 7% of dogs and 21.4% of donkeys (Equus asinus) had lesions with parasites. The agent in the three hosts was identified as Leishmania braziliensis, subspecies braziliensis at least in man and donkey. The probable vector was Lutzomyia panamensis. No infection was found in a small sample of wild mammals examined. The outbreak was apparently linked with the importation of donkeys with ulcers, from endemic areas. The authors call attention to the fact that not only in the foci of "uta", but also in areas of the other forms of American cutaneous leishmaniasis, dogs are frequently found infected. They emphasize the necessity of searching for the infection in donkeys and of performing hemocultures and xenodiagnosis with sandflies in human, canine and equine cases, to verify their possible role as sources of infection, and not merely as dead ends in the epidemiological chain of the disease.     

Feline leishmaniasis: what's the epidemiological role of the cat?

Feline leishmaniasis (FL) is a quite uncommon feature. Clinical disease has been described in cats since nineties begin. More than 40 reports in world literature have been referred, but the clinical cases have been only recently well defined. Most of the reports focus on infected cats living in endemic areas, even if, more recently FL due to Leishmania infantum was found in Sao Paulo State, in Brazil where autochthonous human or canine leishmaniasis cases have never reported. In Europe clinical cases of FL have been described from Portugal, France, Spain and Italy from 1996 to 2002. When a typing of the etiological agent was performed L. infantum was identified in all reported cases. In some endemic areas serological surveys have also been carried out in cats, using IHAT in Egypt, Western blot in France or IFAT in Italy. Sixty Egyptian cats had low serological antibody titers, from 1/32 to 1/128, in the endemic focus of canine leishmaniasis of Alpes Maritimes 12 out of 97 (12.5%) cats showed antibodies versus antigens 14 and/or 18 kDa of L. infantum. A previous survey by means of IFAT in Liguria and Toscana on 110 and 158 feline sera respectively reports a seroprevalence of 0.9% with low titer, while sera from Sicily seem to be positive at higher dilutions. Animals living in an endemic area can develop specific antibodies against leishmania and, in our experience, they can be evidentiated by means of IFAT. The antibody titers appear to be lower in affected cats than in dogs, even if the number of clinical cases is very scanty. PCR tests on feline blood samples are in progress, but preliminary results confirm the presence of leishmania DNA in such specimens. Cutaneous leishmaniasis is the more frequent form in cats and it was reported from several countries. Typical signs include nodular to ulcer or crusty lesions on the nose, lips, ears, eyelids, alopecia: clinical signs of cutaneous FL are unspecific and in endemic area this infection must be taken into account. Visceral leishmaniasis is not common in cats: this form shows visceral involvement: liver and spleen are interested, with lymph nodes and kidney. The cat probably has to considerate to play an active role in the disease, in contrast to goats, calves and horses who could act as accidental reservoirs of leishmania, while sheep appears to be not susceptible to experimental infection. In endemic foci for kala-azar in Sudan cows, goats and donkeys had a high prevalence of specific antibodies. Recently in Europe sporadic cases of equine leishmaniasis have been reported: L. infantum was the causative agent. Equine leishmaniasis appears as a self-healing skin-dwelling disease, with a massive accumulation of parasites. The animals do not often show detectable specific antibodies and recover without any chemotherapy. Untreated affected cats can frequently die and we also observed lymph nodes and blood involvement indicating a spread of leishmania in feline hosts. The epidemiological role of the cat has never been clarified due also to lack of xenodiagnosis trials. This species is believed to have a high degree of natural resistance, as observed following experimental infection. Some of the affected cats were FIV and/or FeLV positive and these viroses such as stress may induce an impaired cellular immune response, even if leishmania infected cat was not submitted to CD4+, CD8+ lymphocyte counts nor other immunological test. However the resistance of the cat to leishmania infection probably depends on genetic factors, not strictly related to cell mediated immunity, taking into account the high seroprevalence of FIV infections (30%) in our country versus the number of clinical cases.     

Prevalence and associated factors of asymptomatic leishmaniasis: a systematic review and meta-analysis

Asymptomatic leishmaniasis is believed to play important role in maintaining the transmission of Leishmania spp. within endemic communities. Therefore, the efforts to eliminate leishmaniasis are daunting if we cannot manage asymptomatic leishmaniasis well. To clarify the global prevalence and factors associated with the asymptomatic Leishmania infection, we assessed the prevalence of asymptomatic leishmaniasis by a systematic review followed by meta-analyses. In addition, factors associated with the asymptomatic leishmaniasis versus symptomatic were also analyzed. We included all of the original articles alluding to the human asymptomatic leishmaniasis that was confirmed by at least one laboratory diagnosis method regardless of age, sex, race, and ethnicity of the patients, study design, publication date or languages. In total, 111 original articles were chosen for the data extraction. Based on our meta-analyses of the original articles reporting asymptomatic leishmaniasis mostly in endemic areas, the prevalence of asymptomatic leishmaniasis was 11.2% [95% confidence interval (CI) 8.6%‐14.4%] in general population, 36.7% [95% CI 27.6%‐46.8%] in inhabitants living in the same or neighboring household to the symptomatic patients, and 11.8% [95% CI 7.1%-19%] in HIV infected patients. Among individuals with leishmaniasis, 64.9% [95% CI 54.7%-73.9%] were asymptomatic and males were more susceptible to develop symptoms, with OR=1.88, 95% CI 1.19-2.99, P=0.007. Meta-regression analysis showed no significant change in the prevalence of asymptomatic leishmaniasis during the last 40 years.     

A case of high altitude cutaneous leishmaniasis in a non-endemic region in Nepal

A case of cutaneous leishmaniasis was discovered in a 32-year old man with a persistent erythematous plaque. The patient resides in a high altitude (~2000 m above sea level) area that is not endemic for cutaneous leishmaniasis in the Dunai village of Dolpa, Nepal. The patient's lesion was initially misdiagnosed as lupus vulgaris. After response failure to initial treatment, additional testing by histological microscopy revealed the presence of Leishmania amastigotes in tissue from the lesion, and the diagnosis of cutaneous leishmaniasis was confirmed by nested PCR DNA assay of tissue from the lesion, and by a positive rK39 test in blood. Sequencing of the kinetoplast region confirmed the presence of Leishmania donovani complex. The patient responded well to treatments for cutaneous leishmaniasis and the skin lesions regressed after 6 months. This is the first known case of cutaneous leishmaniasis in a patient in Nepal who resides at high altitude in a non-endemic region. Increasing temperatures in this region of Nepal may be expanding the range of vectors that transmit cutaneous leishmaniasis.     

Androgen and 19-norandrogen aromatization by equine and human placental microsomes

The ability of equine and human placental microsomes to aromatize testosterone and 19-nortestosterone was studied. When 3 microM [1 beta,2 beta-3H]testosterone was used as substrate, the specific activity of equine placental microsomal aromatase was 2.5 times higher than that of the human microsomal enzyme. Although 19-nortestosterone was aromatized 67 times more rapidly by equine than by human aromatase, we found that equine aromatase exhibited a markedly weaker affinity for this substrate than did the human enzyme. Competitive inhibition of testosterone aromatization by 19-nortestosterone occurred with both equine and human aromatases. While having no effect on mare placental microsomes, Na+ and K+ (500 mM) stimulated testosterone aromatization by human placental microsomes by 73 and 52% respectively. If indeed a single enzyme is responsible for the aromatization of testosterone and 19-nortestosterone, which seems to be the case in both equine and human placental aromatase, our results show that differences in the structure of the active sites exist between equine and human aromatases.     

Leishmaniasis with oral mucosa involvement

doi: 10.1111/j.1741‐2358.2011.00512.x Leishmaniasis with oral mucosa involvement Introduction: The term leishmaniasis comprises a group of diseases caused by different protozoan species of the genus Leishmania. There are three main clinical forms of leishmaniasis: visceral, cutaneous and mucocutaneous. Exclusive involvement of the mucosa is very rare. Objectives: To present a case of mucocutaneous leishmaniasis in an elderly patient, discuss the clinical presentation, diagnostic process and treatment emphasizing the distinctions from other granulomatous lesions. Case report: A 71‐year‐old male presenting with a symptomatic lesion on the hard and soft palate, which had developed over a period of 6 months was evaluated. The oral exam revealed a lesion with multiple ulcerated nodules on the hard and soft palate extending to the oropharynx. The diagnostic hypothesis was chronic infectious disease (paracoccidioidomycose, tuberculosis and leishmaniasis) or squamous cell carcinoma. Histopathological, histochemical and immunohistochemical analysis were performed. A chest x‐ray revealed a normal pulmonary pattern. The Montenegro skin test was positive. The definitive diagnosis was leishmaniasis with exclusive oral manifestation and the patient was treated with liposomal amphotericin. Conclusions: Localized oral mucosa leishmaniasis is an uncommon event in an immunocompetent patient. Dentists play an important role in the diagnosis of oral leishmaniasis, which has systemic repercussions.     

The infection risk of visceral leishmaniasis among household members of active patients

Human visceral leishmaniasis (HVL), caused by Leishmania infantum is mainly observed as sporadic cases in Turkey and dogs are considered as the main reservoir of the disease. The incidence of visceral leishmaniasis among members of households where a HVL infection has already been diagnosed was studied in clusters around the diagnosed cases in different regions in Turkey. A total of 47 serum samples collected from the households of 11 proven visceral leishmaniasis patients were screened for anti-Leishmania antibodies by indirect immunofluorescent antibody test (IFAT). Three and one such household members belonging to the different families were found to be seropositive and borderline, respectively. Diagnosis was confirmed with the presence of amastigotes in bone marrow aspiration samples in all seropositives while the borderline case with slight and indefinitive symptoms of VL was followed only serologically at 3-month intervals and improved spontaneously in 1 year. Household members of individuals with previously confirmed visceral leishmaniasis were found to have higher frequency of the disease suggesting the household members should be included in the risk group for visceral leishmaniasis and serological screening should be performed for the detection of possible infection.     

Molecular Epidemiology of Imported Cases of Leishmaniasis in Australia from 2008 to 2014

Leishmaniasis is a vector borne disease caused by protozoa of the genus Leishmania. Human leishmaniasis is not endemic in Australia though imported cases are regularly encountered. This study aimed to provide an update on the molecular epidemiology of imported leishmaniasis in Australia. Of a total of 206 biopsies and bone marrow specimens submitted to St Vincent’s Hospital Sydney for leishmaniasis diagnosis by PCR, 55 were found to be positive for Leishmania DNA. All PCR products were subjected to restriction fragment length polymorphism analysis for identification of the causative species. Five Leishmania species/species complexes were identified with Leishmania tropica being the most common (30/55). Travel or prior residence in a Leishmania endemic region was the most common route of acquisition with ~47% of patients having lived in or travelled to Afghanistan. Cutaneous leishmaniasis was the most common manifestation (94%) with only 3 cases of visceral leishmaniasis and no cases of mucocutaneous leishmaniasis encountered. This report indicates that imported leishmaniasis is becoming increasingly common in Australia due to an increase in global travel and immigration. As such, Australian clinicians must be made aware of this trend and consider leishmaniasis in patients with suspicious symptoms and a history of travel in endemic areas. This study also discusses the recent identification of a unique Leishmania species found in native kangaroos and a potential vector host which could create the opportunity for the establishment of a local transmission cycle within humans.     

Hombre de 18 años con síndrome verrugoso tropical: ¿leishmaniasis o esporotricosis?

The tropical verrucous syndrome includes infectious, chronic, and granulomatous skin conditions appearing with plaques, nodules, or ulcers with a warty surface which gives name to the syndrome. It includes forms of chromoblastomycosis, sporotrichosis, paracoccidioidomycosis, lobomycosis, leishmaniasis, and tuberculosis verrucosa cutis with ample distribution in tropical and subtropical areas. The diagnoses may be difficult and confused among them, especially between sporotrichosis and leishmaniasis.Clinical, epidemiologic, intradermal reactions, direct smears, skin biopsies, cultures, immunofluorescence, and PCR are used to differentiate them, although several of these methods are not commonly used.We present an 18-year-old man with extensive verrucous plaques in one knee interpreted by clinic, epidemiology, and biopsy as verrucous cutaneous leishmaniasis. He was treated with Glucantime® for 20 days without improvement. A new biopsy was made that was also interpreted as cutaneous leishmaniasis. The revision of both biopsies showed inflammation with abscessed granulomas and asteroid sporotrichotic bodies at the center of the granulomas that led to the diagnosis of sporotrichosis later confirmed by the fungus culture. The patient responded to the treatment with itraconazole. As clinical and epidemiological findings of leishmaniasis and sporotrichosis can be similar, skin biopsy and other paraclinical studies are necessary to establish a proper diagnosis. The asteroid sporotrichotic body is pathognomonic of this mycosis. We review here the essential concepts of leishmaniasis and sporotrichosis and the criteria to differentiate them.     

Direct demonstration of intrinsic follicle-stimulating hormone receptor-binding activity in acid-treated equine luteinizing hormone

After dissociating equine gonadotropins as a function of time at pH 3, we examined them by radioligand assay and sodium dodecyl sulfate polyacrylamide gel electrophoresis under nondissociating conditions (low, 0.1% SDS). Equine follicle-stimulating hormone (FSH) rapidly lost its receptor-binding activity, and low SDS-polyacrylamide gels demonstrated dissociation into subunits. Maximum dissociation occurred after 20–30 min of pH 3 incubation. Equine luteinizing hormone (LH), however, retained most biologic activity and was largely intact after 72 h of pH 3 incubation. Dose-response curves of acid-treated equine LH and FSH and intact equine LH and FSH were compared in five types of radioligand receptor assays. LH and FSH receptor-binding activities of equine LH were unaffected by pH 3. Equine LH showed 19- and 32-times more activity in the rat testis FSH assay than it did in chicken or horse FSH assays, respectively, directly demonstrating the intrinsic FSH receptor-binding activity of equine LH and the relative lack of specificity for these hormone preparations of the rat FSH receptor. Acid-treated equine FSH lost 95% of its biologic activity in FSH assays. In LH assays, the slight (0.2%) activity of equine FSH was relatively unaffected by acid treatment, suggesting that contamination by equine LH accounts for this activity.     

Epidemiology of visceral leishmaniasis through spatial analysis, in Belo Horizonte municipality, state of Minas Gerais, Brazil

The geographic information system approach has permitted integration between demographic, socio-economic and environmental data, providing correlation between information from several data banks. In the current work, occurrence of human and canine visceral leishmaniases and insect vectors (Lutzomyia longipalpis) as well as biogeographic information related to 9 areas that comprise the city of Belo Horizonte, Brazil, between April 2001 and March 2002 were correlated and georeferenced. By using this technique it was possible to define concentration loci of canine leishmaniasis in the following regions: East; Northeast; Northwest; West; and Venda Nova. However, as for human leishmaniasis, it was not possible to perform the same analysis. Data analysis has also shown that 84.2% of the human leishmaniasis cases were related with canine leishmaniasis cases. Concerning biogeographic (altitude, area of vegetation influence, hydrographic, and areas of poverty) analysis, only altitude showed to influence emergence of leishmaniasis cases. A number of 4673 canine leishmaniasis cases and 64 human leishmaniasis cases were georeferenced, of which 67.5 and 71.9%, respectively, were living between 780 and 880 m above the sea level. At these same altitudes, a large number of phlebotomine sand flies were collected. Therefore, we suggest control measures for leishmaniasis in the city of Belo Horizonte, giving priority to canine leishmaniasis foci and regions at altitudes between 780 and 880 m.     

Expression of equine interleukin-18 by baculovirus expression system and its biologic activity

The equine interleukin-18 (IL-18) cDNA that contains the coding sequence was cloned and a recombinant baculovirus, named AcEIL-18, was constructed. The recombinant protein of the equine IL-18 was expressed by AcEIL-18 and its expression was confirmed by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) and Western blotting. Insect cells infected with AcEIL-18 secreted a precursor IL-18 with 24 kilo dalton (kDa) into the culture supernatant. Western blot analysis showed that mature equine IL-18 about 18 kDa was also confirmed without co-expression of caspase-1. Culture supernatant from AcEIL-18 infected cells showed a synergistic effect with recombinant human interleukin-12 for induction of interferon-gamma gene expression in equine peripheral mononuclear cells, indicating that the recombinant equine IL-18 expressed in this study also has biological activity without any treatment.     

Serum neopterin concentrations during treatment of leishmaniasis: useful as test of cure?

Neopterin, a product of gamma-interferon-activated macrophages, was measured in sera from 28 patients (12 patients with cutaneous leishmaniasis and 16 patients with visceral leishmaniasis) to determine the utility as a marker of disease activity and therapeutic efficacy. Patients originated from Kenya (n=5) and from the Academic Medical Center, Amsterdam, The Netherlands (n=23). In seven patients follow-up sera after treatment were available. Two patients at the time of diagnosis of visceral leishmaniasis were co-infected with HIV. The 12 patients with cutaneous leishmaniasis had serum neopterin levels below the upper limit of the normal range. All 16 patients with visceral leishmaniasis had elevated levels of serum neopterin before treatment. In six out of seven patients with visceral leishmaniasis followed during treatment neopterin levels decreased to values below the upper limit of the normal range (10 nmol l(-1)). Sequential measurements of serum neopterin levels may be useful for monitoring therapeutic efficacy in patients with visceral leishmaniasis.     

Study of the superactivity of equine follicle-stimulating hormone in in vitro stimulation of rat Sertoli cells

We have previously shown that equine follicle-stimulating hormone (FSH) stimulates plasminogen activator secretion in Sertoli cells at much lower concentrations than would be expected from its relative binding activity. We have introduced the term 'superactivity' to designate this particular behavior. In the present study, we show that equine FSH triggers a long-lasting (20 h) plasminogen activator secretion, whereas rat, porcine and ovine FSH as well as equine LH and equine choriogonadotropin (CG) provoke a short-term response (2.5 h). Moreover, equine FSH was also shown to be superactive in the stimulation of estradiol secretion and cyclic AMP production. This indicates that the step responsible for the long-term stimulation by equine FSH is not located beyond cAMP accumulation. Equine and porcine FSH were found to be equally stable during incubation with the cells demonstrating that equine FSH superactivity was not due to higher stability. Besides, phosphodiesterase inhibition led to a similar increase in the responses to both hormones. This rules out the possibility that equine FSH superactivity is due to less stimulation of phosphodiesterase activity. All these data strongly suggest that equine FSH exhibits superactivity in rat Sertoli cells by stimulating adenylate cyclase activity for a much longer period of time than do all other gonadotropins. The molecular mechanism of this outstanding behavior remains to be elucidated.     

Indirect immunofluorescence test in New World leishmaniasis: serological and clinical relationship

The indirect immunofluorescence test (IF) for anti-Leishmania antibodies (IgG and IgM) was performed with sera from the following groups of individuals: 214 cutaneous leishmaniasis patients, 28 healthy subjects with positive Montenegro's skin test (MST), 29 healthy subjects with negative MST and 16 visceral leishmaniasis patients. The first four groups came from a suburban area of Rio de Janeiro (Jacarepaguá) where cutaneous leishmaniasis caused by Leishmania braziliensis braziliensis is endemic. It was observed that IF-IgM titers were significantly higher amongst the cutaneous leishmaniasis patients with less than four months of disease as compared to those with longer periods and that IF-IgG titers were significantly higher in patients with multiple lesions as compared to those with single lesions. The visceral leishmaniasis patients had IF-IgG titers significantly higher than those from cutaneous leishmaniasis patients. A group of 28 individuals selected amongst the 214 cutaneous leishmaniasis patients had their IF-titers (IgG and IgM) compared to those of the two control groups of healthy subjects from the endemic area, respectively with positive and negative MST. Significantly higher titers of IF-IgG and IF-IgM were found in the group with active disease. The same group of patients showed IF-IgG titers significantly lower at the end of the antimonial therapy than those observed during this treatment.     

Clinical and immunopathological spectrum of American cutaneous leishmaniasis with special reference to the disease in Amazonian Brazil: a review

The wide variety of Leishmania species responsible for human American cutaneous leishmaniasis combined with the immune mechanisms of the host results in a large spectrum of clinical, histopathological, and immunopathological manifestations. At the middle of this spectrum are the most frequent cases of localized cutaneous leishmaniasis (LCL) caused by members of the subgenera Leishmania and Viannia, which respond well to conventional therapy. The two pathogenicity extremes of the spectrum generally recognized are represented at the hypersensitivity pole by mucocutaneous leishmaniasis (MCL) and at the hyposensitivity pole by anergic diffuse cutaneous leishmaniasis (ADCL). Following the present study on the clinical, histopathological and immunopathological features of cutaneous leishmaniasis in Amazonian Brazil, we propose the use of the term "borderline disseminated cutaneous leishmaniasis" for the disseminated form of the disease, due to parasites of the subgenera Leishmania and Viannia, which might be regarded as intermediate between LCL and the extreme pathogenicity poles MCL and ADCL.     

Characterization of the immune response to Leishmania infantum recombinant antigens

Leishmaniases have a high prevalence in tropical countries. In order to improve existing diagnostic systems based on total Leishmania proteins, and to identify antigen candidates for vaccine development, an intensive search for the identification of antigens was performed using molecular biology techniques. In this study, the immune response to three L. infantum recombinant antigens was evaluated. Upon stimulation with KMP11, mononuclear cells from leishmaniasis patients produced high levels of IL-10, while a predominant IFN-gamma production could be observed in cultures stimulated with H2A and soluble Leishmania antigen. All the recombinant antigens induced very little IL-5. KMP11 decreased IFN-gamma production by 48% in cultures of peripheral blood mononuclear cells from cutaneous leishmaniasis patients who had been stimulated with soluble Leishmania antigen. Furthermore, antibodies to KMP11 were detected in the sera from all patients with visceral leishmaniasis and in the majority of the sera from patients with cutaneous leishmaniasis or individuals with asymptomatic L. chagasi infection. Thus, KMP11 is recognized by cells and sera of patients with different clinical forms of leishmaniasis, and KMP11, through IL-10 production, proved to be a potent antigen in modulating type 1 immune response.