Epidemiologic surveillance of visceral leishmaniasis in Sicily, Italy

Trans-Atlantic Spill Over: Deconstructing the Ecological Adaptation of Leishmania infantum in the Americas

Pathogen fitness landscapes change when transmission cycles establish in non-native environments or spill over into new vectors and hosts. The introduction of Leishmania infantum in the Americas into the Neotropics during European colonization represents a unique case study to investigate the mechanisms of ecological adaptation of this important parasite. Defining the evolutionary trajectories that drive L. infantum fitness in this new environment are of great public health importance as they will allow unique insight into pathways of host/pathogen co-evolution and their consequences for region-specific changes in disease manifestation. This review summarizes current knowledge on L. infantum genetic and phenotypic diversity in the Americas and its possible role in the unique epidemiology of visceral leishmaniasis (VL) in the New World. We highlight the importance of appreciating adaptive molecular mechanisms in L. infantum to understand the parasites' successful establishment on the continent.

Leishmania infantum in wild animals in endemic areas of southern Italy

Leishmania infantum infection in wildlife is increasingly reported in Europe, but scant data are available in Italy so far. This study aimed to investigate the circulation of L. infantum among sylvatic hosts in Sicily (southern Italy), a highly endemic area for canine leishmaniosis, through serological and molecular tools. Target tissues (skin, spleen, lymph nodes) collected from 71 European rabbits, 2 European hares, 7 red foxes, 11 European wildcats and 1 pine marten, were qPCR analysed for the detection of L. infantum DNA. Additionally, 40 rabbits, older than one year, were serologically screened for specific anti-Leishmania antibodies. Leishmania infantum was molecularly diagnosed in 5.4% (n = 5) of the examined animals (3/71 European rabbits, 2/7 red foxes). In many of the qPCR positive animals (4/5), the parasite DNA was more prevalent in visceral than cutaneous tissues. None of the positive animal showed signs of disease and/or macroscopic alterations of organs; low parasitic burden in all positive tissue samples was also recorded. Only one rabbit serum (i.e., 2.5%) tested positive for anti-Leishmania antibodies. The seropositive rabbit was in good health status and no amastigotes were observed in lymph-node aspirate and blood smears. This study provides first evidence of L. infantum infection in wild animals from Sicily (southern Italy). Despite the low prevalence of infection here reported, the circulation of the Leishmania in wild reservoirs in Sicily remains worthy of future investigations for a better understanding of their role in the epidemiology of the disease as well as to fine-tune control strategies in the area.

Worldwide risk factors in leishmaniasis

Recently, vector-borne parasitic diseases such as leishmaniasis have been emerged or re-emerged in many geographical areas and resulted in global health and economic concerns that involve humans, domestic animals and wild life. The ecology and epidemiology of leishmaniasis are affected by the between host, reservoir and vector (human, animal and sandfly) and the environment. Important drivers for the emergence and spread of leishmaniasis include environmental factors such as alterations in temperature and water storage, irrigation habits, deforestation, climate changes, immunosuppression by HIV or organ transplant, development of drug resistance, increase traveling to endemic regions and dog importation. War, poor socio-economic status and low level household are also major contributors to the spread of this disease. Health education via the public media and training should be implemented by international organizations and governmental agencies in collaboration with research institutions. Fully protection during transmission season, using bednets and insecticides and reservoirs' control should be also mentioned in the planning. Based on the findings of the recent studies and high prevalence of leishmaniasis, it is concluded that serious public health monitoring should be considered.

Effect of night time-intervals, height of traps and lunar phases on sand fly collection in a highly endemic area for canine leishmaniasis

The activity of phlebotomine sand flies was monitored in a sub-urban area of Sicily in order to acquire data on seasonality and to elucidate the effect of the night time-intervals, height of traps from ground and lunar phases on the abundance of the capture. The study was conducted in the farm of the University of Messina (Italy). Light traps were placed as in the following: biweekly, from dusk to dawn, and from May to November; for three consecutive nights from 18:00 to 6:00, with the net bag being changed every 2h; for 30 days, at different heights from 18:00 to 6:00. A total of five species (i.e., Phlebotomus perniciosus, Phlebotomus neglectus, Phlebotomus sergenti, Phlebotomus perfiliewi, and Sergentomyia minuta), three of which are proven vectors of Leishmania infantum, were captured. The most abundant species was P. perniciosus (73.3%) followed by S. minuta (23.3%). The highest number of phlebotomine sand flies was collected in August and September with a peak of collection recorded in the evening (i.e., from 20:01 to 22.00). The number of phlebotomine sand flies collected at 50cm above the ground was significantly higher (P=0.041) than that captured at 150cm. Results of this study shed light on the ecology of main phlebotomine species in the Mediterranean area, and on the influence of some factors, such as time and height of traps, on the light trap capture efficiency.

Five-year retrospective Italian multicenter study of visceral leishmaniasis treatment

The treatment of visceral leishmaniasis (VL) is poorly standardized in Italy in spite of the existing evidence. All consecutive patients with VL admitted at 15 Italian centers as inpatients or outpatients between January 2004 and December 2008 were retrospectively considered; outcome data at 1 year after treatment were obtained for all but 1 patient. Demographic characteristics, underlying diseases, diagnostic procedures, treatment regimens and outcomes, as well as side effects were recorded. A confirmed diagnosis of VL was reported for 166 patients: 120 (72.3%) immunocompetent, 21 (12.6%) patients with immune deficiencies other than HIV infection, and 25 (15.1%) coinfected with HIV. Liposomal amphotericin B (L-AmB) was the drug almost universally used for treatment, administered to 153 (92.2%) patients. Thirty-seven different regimens, including L-AmB were used. The mean doses were 29.4 ± 7.9 mg/kg in immunocompetent patients, 32.9 ± 8.6 mg/kg in patients with non-HIV-related immunodeficiencies, and 40.8 ± 6.7 mg/kg in HIV-infected patients (P < 0.001). The mean numbers of infusion days were 7.8 ± 3.1 in immunocompetent patients, 9.6 ± 3.9 in non-HIV-immunodeficient patients, and 12.0 ± 3.4 in HIV-infected patients (P < 0.001). Mild and reversible adverse events were observed in 12.2% of cases. Responsive patients were 154 (93.3%). Successes were 98.4% among immunocompetent patients, 90.5% among non-HIV-immunodeficient patients, and 72.0% among HIV-infected patients. Among predictors of primary response to treatment, HIV infection and age held independent associations in the final multivariate models, whereas the doses and duration of L-AmB treatment were not significantly associated. Longer treatments and higher doses of L-AmB were not able to significantly modify treatment outcomes either in the immunocompetent or in the immunocompromised population.

Paediatric visceral leishmaniasis in Italy: a 'One Health' approach is needed

Here we describe a case of paediatric visceral leishmaniasis recorded in an infant initially suspected for acute lymphoblastic leukaemia due to the clinical and haematological presentation. Eventually the patient was found positive for Leishmania infantum infection and successfully treated. This case emphasises how pivotal a ‘One Health’ approach is for diagnosing this zoonotic disease; highlighting the importance of including Visceral Leishmaniasis in the differential diagnosis of leukaemia-like syndromes in infants travelling to, and living in, the Mediterranean region.

[Visceral leishmaniasis in immunocompetent adults. About six cases]

OBJECTIVE

Studying the epidemiological variations of visceral leishmaniasis in Tunisia and proving the importance of parasitological investigations to raise the diagnosis.

PATIENTS AND METHODS

Six patients hospitalised during the period between January 1998 and January 2009 at Fattouma Bourguiba Teaching Hospital in Monastir, five men and an only one woman, aged from 26 to 70 years old, originating from the central and eastern regions of the country. Epidemiological, clinical, biological and therapeutic data were obtained from the patient's medical files.

RESULTS

The major clinical symptoms were fever, weakness and spleen enlargement. Biological data revealed the presence of anaemia in every case and leucopoenia associated or not associated with thrombopenia in four cases. The diagnosis of visceral leishmaniasis was confirmed by the identification of the parasite in the blood or in the bone marrow. All patients were treated with two courses of antimoniate of meglumine separated by a 6-week interval. The outcome was positive and the patients were cured.

CONCLUSION

Visceral leishmaniasis is increasing among adults in Tunisia. Moreover, it is spreading outside its epidemiological area in the north to reach the central and southern regions. It should be raised when fever and spleen enlargement occur. Biological data are hardly specific. Diagnosis is based on finding the parasite in human fluids, mainly by molecular techniques. The rapid establishment of a specific treatment is vital.

Visceral leishmaniasis in 26 HIV-negative adults

BACKGROUND

Visceral leishmaniasis is a notifiable parasitic disease that had increased in incidence in our region on the past few years. It is common in children. In adults, it occurs more on a background of immunodeficiency, and frequently with incomplete clinical manifestations, making the diagnosis complicated.

FINDINGS

The aim of our study is to reveal different features of visceral leishmaniasis in adults, through the analysis of its epidemiological, clinical and biological parameters, in a group of 26 patients. No one was infected with HIV or under immunosuppressive therapy Clinical presentation was generally conservative, but there was few differences in adults compared to children, concerning both the clinical symptoms and the laboratory parameters. Diagnosis was provided by direct examination of bone marrow smears in 24 cases (sensitivity 92%), and anti-leishmanial serology in the others.

CONCLUSION

We should think to the diagnosis of VL even if the patient is not known immunocompromised, and even if the clinical is incomplete, to avoid a delay of care which can lead to serious complications.

Asymptomatic Leishmania infantum infection in an area of northwestern Italy (Piedmont region) where such infections are traditionally nonendemic

The prevalence of Leishmania infantum-specific antibodies and asymptomatic infection was assessed in a randomized sample of 526 healthy adults from a continental area of northwestern Italy where L. infantum is not endemic and where autochthonous cases of visceral leishmaniasis (VL) were recently reported. L. infantum-specific antibodies were detected by Western blotting (WB) in 39 subjects (7.41%), while L. infantum kinetoplast DNA was amplified from buffy coat in 21 out of 39 WB-positive subjects, confirming asymptomatic infection in 53.8% of seropositives. Risk factors significantly associated with WB positivity were uninterrupted residence since childhood in a local rural environment (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.7 to 7.3), daily contact with animals though not exclusively with dogs (OR, 3.7; 95% CI, 1.3 to 10.7), older age (OR, 2.31; 95% CI, 1.2 to 4.5), and agricultural/other outdoor activities (OR, 3.8; 95% CI, 0.99 to 3.7.) Logistic regression analysis showed that uninterrupted residence in a local rural environment and an age of >65 years were the only independent predictors of seropositivity assessed by WB. Follow-up at 24 months did not show evidence of VL in either seropositive or PCR-positive subjects. The detection of a high seroprevalence rate, confirmed as asymptomatic infection by PCR in more than half of the cases, among healthy residents in a continental area of northwestern Italy makes local L. infantum transmission very likely. In a region where VL is considered nonendemic, these findings warrant further epidemiological investigations as well as interventions with respect to both the canine reservoir and vectors, given the possible risks for immunosuppressed patients.

Sandflies and sandfly-borne infections of humans in Central Europe in the light of climate change

In Europe, sandflies (Diptera: Psychodidae: Phlebotominae) are typical Mediterranean faunal elements of low expansivity, which are widely distributed in more than 20 species in many parts of Southern Europe. A few species have extended their distribution to the northwest invading extramediterranean regions (Western, Eastern Europe); any occurrence in Central Europe north of the Alps was excluded until recently. Since 1999 sandflies have been found in several parts in Germany and in Belgium; originally these records were ascribed to climate change and global warming. Meanwhile, the more likely assumption is that sandflies have always, probably since the Holocene climate optima (ca. 4500 and 2500 B.C.), been in Central Europe sporadically to where they have come as immigrants (or re-immigrants) from Mediterranean refugial areas. It is, however, without question that global warming will lead to an extension of the distributional areas of sandflies. A climatological analysis of the localities where sandflies have been found in Central Europe has revealed that temperature is the key factor. A comparison of climatological parameters in sandfly-localities with the climatic conditions in Austria (where sandflies have not yet been found) has shown that an increase of temperature by 1 degrees C in January (Ph. mascittii) or 1 degrees C in July (Ph. neglectus), respectively, would lead to suitable conditions for the occurrence of sandflies in certain parts of Austria. (The scenarios for an increase of temperature until the end of the century vary between 1.5 degrees C to 4.5 degrees C; 3 degrees C seem to be realistic also for critical climatologists.) Leishmaniae certainly do not occur in Central Europe primarily, but an increasing number of infections in humans, as well as in animals, acquired in Central Europe has been registered. It is highly likely that these infections are due to sandflies which have been infected by sucking blood on infected dogs. Dogs infected with Leishmania and presenting a variety of clinical symptoms are frequently brought by compassionate tourists from Mediterranean countries - often illegally - to Central Europe. Meanwhile, a flourishing market for dogs of miserable appearance suffering from leishmaniosis has been developed by profit-oriented opportunists in Mediterranean countries. With respect to the serious course of visceral leishmaniosis (particularly in infants and in immunocompromised persons) this dangerous condition merits intensive attention. Phleboviruses have not been found in Central Europe, so far. However, in the course of global warming an establishment of biological cycles after an introduction of the pathogens, particularly if vertebrates other than humans can also act as reservoir hosts, seems possible.

Recombinant K39 immunochromatographic test for diagnosis of human leishmaniasis

A new recombinant K39 immunochromatographic test (ICT) was compared with the immunofluorescent antibody assay (IFA) for the rapid serological diagnosis of visceral leishmaniasis (VL) in Apulia, Southern Italy. A total of 264 individuals were tested, including 19 patients with VL (three of which were HIV positive), 67 individuals with suspected VL, 40 healthy controls and 138 patients with other diseases. The ICT was positive in all 19 patients with VL and negative in sera from the remaining individuals. Both the sensitivity and specificity of ICT was 100%. The ICT also worked well in HIV–Leishmania co-infected patients. Antibodies to Leishmania detected by the IFA and ICT remained at detectable levels for up to 12–24 months. A positive reaction by the ICT was detectable at a serum dilution of up to 1:20,480, indicating that a strong immunoresponse is mounted against the recombinant K39 antigen. In conclusion, the ICT is highly sensitive, specific, rapid, noninvasive and cost effective (€8.43 for ICT and €12 for IFA) in the diagnosis of VL in areas of low VL endemicity.

[The epidemiology of hospital admissions due to leishmaniasis in Spain (1999-2003)]

OBJECTIVE

The aim of this study was to determine the epidemiology of patients hospitalized for leishmaniasis during the period 1999 to 2003.

PATIENTS AND METHODS

This is a retrospective study using the Minimum Data Set for Hospital Discharge (CMBD, Conjunto Mínimo Básico de Datos al alta hospitalaria), a national surveillance system database.

RESULTS

There were 1,180 hospital admissions with a primary diagnosis of leishmaniasis, 34% of which were readmissions, yielding a total of 786 new cases of leishmaniasis and an incidence rate of 0.4 per 100,000 population/year. The disease mainly affected children under five years of age and adults between 25 and 44. The most frequent form of presentation was visceral leishmaniasis, which was documented in 83.6% of hospitalizations. Among the autonomous communities of Spain, Madrid and Castilla-La Mancha showed the highest incidence rates, whereas Galicia and Extremadura presented the lowest rates. Patients coinfected with HIV accounted for 42% of hospital admissions for leishmaniasis. Nonetheless, between 2000 and 2003, a decrease was observed in the number of hospitalizations in this subgroup and an increase of patients without HIV coinfection.

CONCLUSION

The increase in hospitalization rates for leishmaniasis in Spain indicates that this avoidable zoonosis remains a considerable public health problem in our country.

Studies on the CPA cysteine peptidase in the Leishmania infantum genome strain JPCM5

Background

Visceral leishmaniasis caused by members of the Leishmania donovani complex is often fatal in the absence of treatment. Research has been hampered by the lack of good laboratory models and tools for genetic manipulation. In this study, we have characterised a L. infantum line (JPCM5) that was isolated from a naturally infected dog and then cloned. We found that JPCM5 has attributes that make it an excellent laboratory model; different stages of the parasite life cycle can be studied in vitro, it is accessible to genetic manipulation and it has retained its virulence. Furthermore, the L. infantum JPCM5 genome has now been fully sequenced.

Results

We have further focused our studies on LiCPA, the L. infantum homologue to L. mexicana cysteine peptidase CPA. LiCPA was found to share a high percentage of amino acid identity with CPA proteins of other Leishmania species. Two independent LiCPA-deficient promastigote clones (ΔLicpa) were generated and their phenotype characterised. In contrast to L. mexicana CPA-deficient mutants, both clones of ΔLicpa were found to have significantly reduced virulence in vitro and in vivo. Re-expression of just one LiCPA allele (giving ΔLicpa::CPA) was sufficient to complement the reduced infectivity of both ΔLicpa mutants for human macrophages, which confirms the importance of LiCPA for L. infantum virulence. In contrast, in vivo experiments did not show any virulence recovery of the re-expressor clone ΔLicpaC1::CPA compared with the CPA-deficient mutant ΔLicpaC1.

Conclusion

The data suggest that CPA is not essential for replication of L. infantum promastigotes, but is important for the host-parasite interaction. Further studies will be necessary to elucidate the precise roles that LiCPA plays and why the re-expression of LiCPA in the ΔLicpa mutants complemented the gene deletion phenotype only in in vitro and not in in vivo infection of hamsters.

Serological screening for Leishmania infantum in asymptomatic blood donors living in an endemic area (Sicily, Italy)

The purpose of our study was to assess whether Leishmania infantum parasitemia occurs in asymptomatic Leishmania-seropositive subjects. Samples from 500 blood donors were tested using an enzyme-linked immunosorbent assay (ELISA). Anti-Leishmania antibodies were not found in any sample. Our findings suggest that the risk of L. infantum transmission by blood transfusion in Sicily is very low.

Leishmania chagasi/infantum: further investigations on Leishmania tropisms in atypical cutaneous and visceral leishmaniasis foci in Central America

In Central America, apparently genetically identical Leishmania chagasi/infantum parasites cause cutaneous (CL) and visceral leishmaniasis (VL), the latter being more frequent in young children. The present study investigated if there were pathology-related differences in virulence between Honduran CL and VL strains using Mediterranean L. infantum strains as a reference. Macrophage infectivity and serum sensitivity, properties thought to be associated with virulence, were similar between CL and VL strains from both regions. Attention focused on the genome organisation of genes for two candidate virulence factors: Leishmania mitogen activated protein kinase (LMPK) and cysteine proteinase b (Cpb). Interestingly, the Mediterranean strains exhibited restriction enzyme polymorphisms associated with tropism for both LMPK and Cpb genes whereas no differences were observed for the Honduran strains. We also report relative genetic homogeneity of the Honduran strains as compared to the Mediterranean strains and discuss it in terms of the probable origin for the Central American L. chagasi/infantum.

Visceral leishmaniasis treatment, Italy

First-line drug treatment was recorded in 573 immunocompetent patients with visceral leishmaniasis in Italy. In the past 12 years, the proportion of antimonial treatments decreased from 100% to 2.8%, while the proportion of amphotericin B treatments increased from 0% to 97.2%. The countrywide change in therapy is a response to both disease reemergence and increasing antimonial failure.

Host preferences of phlebotomine sand flies at a hypoendemic focus of canine leishmaniasis in central Italy

A survey was carried out on phlebotomine sand flies and their feeding habits at a hypoendemic focus of Leishmania infantum in Macerata province, central Italy. During two consecutive years (2000-2001), 1465 sand fly specimens (42.5% of which were males) were collected from a variety of diurnal resting sites in the municipality of Camerino. The most prevalent species was Phlebotomus perniciosus (76.6%), followed by P. papatasi (10.4%), Sergentomyia minuta (9.1%), Phlebotomus perfiliewi (3.3%) and P. mascittii (0.5%). Among the 842 females collected, 578 (68.6%) were blood-fed. Based on the results of blood meal analyses, P. perniciosus fed on man, dogs, equines, sheep and birds; P. perfiliewi on dogs, equines, sheep and birds; P. papatasi on dogs, equines and birds. Two specimens of P. mascittii fed on equines. Forage ratios (FRs) and host selectivity indices gave different results for the large domestic animals. More than 95% of the specimens collected inside a stable, dog kennel, sheep pen and chicken house were found to have fed on the animals housed in the respective shelters. In addition, at one collecting site where almost all the hosts mentioned above were present simultaneously, both P. perniciosus and P. perfiliewi were found to have fed on all five species, indicating that host choice was probably related to its availability (i.e. number and size) rather than specific attractiveness. The feeding habits of the two Leishmania vectors may have implications for the epidemiology of leishmaniasis in urban and peri-urban areas, where sand fly females deprived of other vertebrate hosts (particularly the larger species) may begin to bite humans and dogs more frequently.

Control of phlebotomine sandflies

Phlebotomine sandflies (Diptera: Psychodidae) transmit many zoonotic diseases (arboviruses, bartonelloses and especially leishmaniases) of importance to human health in at least 80 countries. Measures used to control adult sandflies (Lutzomyia and Phlebotomus) include the use of insecticides (mostly pyrethroids) for residual spraying of dwellings and animal shelters, space-spraying, insecticide-treated nets, impregnated dog-collars and personal protection through application of repellents/insecticides to skin or fabrics. Because the breeding-sites of sandflies are generally unknown, control measures that act specifically against immatures are not feasible, although the effectiveness of a few biological and chemical agents has been demonstrated in laboratory evaluations. Reports of insecticide-resistance refer to only three sandfly species (P. papatasi, P. argentipes and S. shorttii) against DDT in one country (India), although there are reports of DDT-tolerance in several countries. Current knowledge of sandfly susceptibility to various insecticides is summarized. Constraints and advantages of different compounds, formulations and delivery methods for sandfly control under different environmental conditions are discussed.

Polymerase chain reaction in the diagnosis and prognosis of Mediterranean visceral leishmaniasis in immunocompetent children

OBJECTIVE

To assess the usefulness of a polymerase chain reaction (PCR) assay amplifying the small subunit rRNA coding region of Leishmania species performed on peripheral blood (PB) and bone marrow (BM) aspirates for the diagnosis and follow-up of visceral leishmaniasis (VL) in children living in the Mediterranean basin.

DESIGN

A prospective study was conducted on children consecutively hospitalized over a 1-year period at our Infectious Diseases Department in Sicily (Italy) presenting with fever, hepatosplenomegaly, and/or pancytopenia and a positive Leishmania serology (> or =1:40).

RESULTS

Among the 14 patients hospitalized with signs and symptoms suggestive of the disease and a positive serology, we identified 10 cases of Mediterranean VL. PCR performed on PB and BM aspirates was positive in all cases and concordant with microscopy and/or culture performed on BM. Leishmania DNA was cleared from PB a median of 6 days after the start of treatment; during follow-up (median: 9 months; range: 6-12 months) 1 child relapsed. In this case, BM PCR remained positive with rapid reappearance of a positive signal also in PB.

CONCLUSIONS

PB PCR allows a rapid and noninvasive parasitologic diagnosis of Mediterranean VL among immunocompetent children and is at least as sensitive as a diagnosis made on the basis of BM aspirates. The lack of disappearance from BM and the reappearance of positive PCR on PB is predictive of clinical relapse. Qualitative and semiquantitative PCR may be the standard method for monitoring response to therapy in immunocompetent children.

Treatment of visceral leishmaniasis (kala-azar): a decade of progress and future approaches

In 1990, there was essentially one treatment regimen in use for visceral leishmaniasis (kala-azar) around the world: 20 to 28 days of daily injections of pentavalent antimony (Sb). During the past 10 years, however, new agents have been tested alone or in combination, in more than 50 studies carried out worldwide. This renewed clinical effort was spurred by a variety of factors, including the emergence of large-scale Sb unresponsiveness in India, where up to one-half of the world's cases of kala-azar now are found. As this new decade opens, the success of this clinical research effort is tangible: three additional, highly effective parenteral regimens now are available (amphotericin B, lipid formulations of amphotericin B, aminosidine), and an active oral agent, a long sought after objective in kala-azar, has been identified (miltefosine). This report reviews the evolution of treatment of visceral leishmaniasis, considers the interaction of the immune response and chemotherapy, highlights therapeutic successes and failures, examines advantages and disadvantages of current treatments, and looks at future therapeutic approaches to the management of this disseminated intracellular protozoal infection.

Nitric oxide production by macrophages of dogs vaccinated with killed Leishmania infantum promastigotes

Human visceral leishmaniosis is endemic in Southern Italy, where the dog is the main reservoir of viscerotropic strains of Leishmania infantum. The release of nitric oxide (NO) by interferon (IFN)-gamma-activated macrophages is an important leishmanicidal mechanism in several animal species. In this work NO production, phagocytosis and killing capacity of monocyte-derived dog macrophages were evaluated in vitro before and after administration of a vaccine composed of killed Leishmania infantum promastigotes. Moreover, IFN-gamma content was measured in concanavalin A-activated dog peripheral blood mononuclear cell (PBMC) supernatants employed for macrophage stimulation. Phagocytosis, killing capacity and NO production by canine macrophages increased significantly 1 month after vaccine administration, and the increase also persisted 5 months later. In addition, the amount of IFN-gamma in PBMC supernatants was significantly higher after vaccination. Overall, our results suggest the usefulness of evaluating the in vivo protective role of this promastigote preparation in dogs.

Visceral leishmaniasis in human immunodeficiency virus (HIV)-infected and non-HIV-infected patients. A comparative study

Visceral leishmaniasis is an endemic infection in Mediterranean countries, where it has become a frequent complication of acquired immunodeficiency syndrome (AIDS). The incidence of visceral leishmaniasis is increasing in Spain due to human immunodeficiency virus (HIV)-related cases, but some aspects of its epidemiology, clinical features, and management remain unknown. In addition, no comparative clinical studies about the disease in HIV-infected and non-HIV-infected patients have been reported. During a 24-year period, 120 cases of visceral leishmaniasis were diagnosed at our institution and 80 (66%) were associated with HIV infection. The mean age at diagnosis was higher in HIV-infected that in non-HIV-infected patients (33.2 versus 23.2 yr; p = 0.002), but the male/female ratio was similar in both groups. The main risk factor for HIV infection was intravenous drug abuse (78.7%). The clinical presentation of leishmaniasis was similar in both groups, but HIV-infected patients had a lower frequency of splenomegaly than HIV-negative individuals (80.8% versus 97.4%; p = 0.02). HIV-infected patients had a greater frequency and degree of leukopenia, lymphocytopenia, and thrombocytopenia. Most of them were profoundly immunosuppressed (mean CD4+ lymphocyte count, 90 cells/mm3) at the time of diagnosis of leishmaniasis, and 53.7% had AIDS. The sensitivity of serologic studies for Leishmania was significantly lower in HIV-infected than in non-HIV-infected patients (50% versus 80%; p < 0.001), but the diagnostic yield of bone marrow aspirate (67.1% versus 79.4%) and bone marrow culture (62.9% versus 66.6%) was similar in both groups. After initial treatment, the response rate was significantly lower in HIV-infected than in non-HIV-infected individuals (54.8% versus 89.7%; p = 0.001). The relapse rate was 46.2% and 7.5%, respectively (p < 0.001). Secondary prophylaxis with antimonial compounds or amphotericin B seems to be useful in preventing relapses in HIV-infected patients. The mortality rate was higher (53.7% versus 7.5%; p < 0.001) and the median survival time shorter (25 versus > 160 mo; p < 0.001) in AIDS patients than in HIV-negative individuals. Although leishmaniasis could contribute to death in a significant number of HIV-infected patients, it was the main cause of death in only a few of them. The CD4+ lymphocyte count and the use of highly active antiretroviral therapy and secondary prophylaxis for leishmaniasis were the most significant prognostic factors for survival in AIDS patients. Visceral leishmaniasis behaves as an opportunistic infection in HIV-infected individuals and should be considered as an AIDS-defining disease.

Suppression of posttreatment recurrence of experimental visceral Leishmaniasis in T-cell-deficient mice by oral miltefosine

T-cell-deficient nude mice infected with Leishmania donovani were treated with miltefosine and then given either no treatment or intermittent miltefosine. Intracellular visceral infection recurred in untreated mice but was suppressed by once- or twice-weekly oral administration of miltefosine. Miltefosine may be useful as oral maintenance therapy for T-cell-deficient patients with visceral leishmaniasis.

Detection of Leishmania infantum in dogs by PCR with lymph node aspirates and blood

The PCR technique was applied to the diagnosis of leishmaniasis in dogs, both serologically negative and positive. DNA was taken from lymph node aspirates and blood. The primers 13a and 13b, derived from Leishmania amazonies and Leishmania braziliensis kinetoplast DNA (kDNA), also amplified Leishmania infantum IPT1 constant region of minicircle kDNA. The amplified fragment is 116 bp long. It was cloned and the sequence was determined. A 70-bp inner fragment was designed and used as a probe in dot blot hybridization. A group of 124 dogs was examined, 37 of which showed typical symptoms of disease. PCR was performed on 124 blood samples and 52 lymph node aspirates. Using microscopic examination as the "gold standard," we calculated sensitivity, specificity, and positive and negative predictive values of 100% using lymph node aspirates and values of 85, 80, 95, and 57%, respectively, using blood samples. We found that 40% of the animals without lesions and 38% of the animals with clinical signs gave false-negative results by indirect immunofluorescence antibody testing. These animals could contribute to the spreading of infection among dogs, and represent a potential risk for human health as well.

Kala-azar as an AIDS-related opportunistic infection

Visceral leishmaniasis (kala-azar) is a worldwide disseminated protozoal infection primarily transmitted by sand flies. Because host defense against this intracellular infection is T-cell-dependent, kala-azar has predictably joined the list of AIDS-related opportunistic infections in endemic areas. The vast majority of patients with AIDS-associated kala-azar are currently found in southern Europe (the Mediterranean basin, especially Spain in injection drug users); future cases will inevitably arise in other endemic regions including India, East Africa and Sudan, and Brazil. In CD4 cell-deficient HIV-infected individuals, kala-azar likely represents recrudescence of previously controlled asymptomatic infection; in drug users, newly acquired infection may result from transmission via shared needles. Coinfected patients are frequently parasitemic and may show atypical clinical presentations, unusual multi-organ involvement, and absent antileishmanial antibodies. Diagnosis is made by microscopic examination or culture of aspirate or biopsy of any involved tissue (primarily bone marrow) or by blood smear or culture. Conventional treatment (pentavalent antimonials) induces initial remission in about 50% of patients; amphotericin B and its new lipid formulations appear more active. If suppressive maintenance therapy is not used, relapse within 1 year is typical. In AIDS patients with a first episode of visceral kala-azar, up to 25% die within 1 month if treatment is stopped. Optimal primary and secondary prophylaxis for AIDS-related kala-azar remain to be determined; life-long maintenance therapy is becoming an accepted approach.

Flow cytometric assessment of amphotericin B susceptibility in Leishmania infantum isolates from patients with visceral leishmaniasis

Amphotericin B susceptibility was measured by a flow cytometric membrane potential assay in Leishmania infantum promastigotes isolated from 11 immunocompetent children treated with liposomal amphotericin B and 19 HIV-infected young adults treated with intralipid amphotericin B. Susceptibility levels were measured by the 90% inhibitory concentrations (IC90) representing the concentrations of drug that induced a 90% decrease in membrane potential compared with the control culture. In immunocompetent children, treatment was fully effective whatever the susceptibility of isolates to amphotericin B. In immunocompromised adults, on the contrary, unresponsiveness and relapses could be observed in all cases and IC90 increased in the course of successive treatments: a decrease of amphotericin B susceptibility in both promastigote and amastigote forms could be observed in a patient who had six relapses. These results suggest that the success of amphotericin B treatment depends greatly on patient immunity status, and indicate that successive relapses could enhance emergence of amphotericin B resistant isolates. The results demonstrate that the flow cytometric membrane potential assay can be used as an easy and reliable tool for studying the evolution of interactions between amphotericin B and the parasite membrane during long-term treatments.

The compromised traveler

Compromised travelers represent a diverse and challenging group of individuals. They include HIV-infected patients who are at risk for potentially adverse reactions to immunizations, and new exposures to enteric water-borne opportunistic pathogens associated with chronic infections. Such travelers may encounter unfamiliar opportunistic fungi and classical tropical infections, such as leishmaniasis, whose pathogenesis can be enhanced by the presence of prior HIV infection. Other immunocompromised groups include those who are functionally or anatomically asplenic, and patients who are iatrogenically immunosuppressed from medications utilized for solid organ transplantation, chemotherapy, or treatment of malignancies. This population of travelers also includes those with diabetes mellitus who may require adjustments in their dosing, administration, and possibly even the types of insulin used on their trips. These patients are also at greater risk for acquisition of tuberculosis, severe community-acquired pneumonia, urinary tract infections, and pyomyositis. Older travelers present both the infectious disease and travel medicine specialist with issues such events, malignancy-related infections, myocardial infarction, and other forms of cardiopulmonary compromise, which the authors address in this article.