I- Overview :
→ Parasitic protozoan of the genus Leishmania; having in common:
– Epidemiology: transmission by dipteran, sandfly;
– pathophysiology : Leishmania infect macrophages, mononuclear phagocytes) Host.
Therapeutic: the same MDCT are active.
→ Three types of leishmaniasis:
- L. visceral or Kala Azur
- L. cutaneous.
- L. mucocutaneous
II- INTEREST QUESTION :
- Affection spontaneous evolution is fatal; for which there is a specific TRT ensuring permanent cure.
- Disease n & rsquo; is not uncommon in our country and is currently in expansion.
- Preventive measures are possible.
III- PARASITOLOGIOUES DATA :
1- the parasite :
- Branch : protozoaire.
- Class : flagellated
- Order : kinetoplastidae.
- Family : trypanosomatidae.
- Genre: leishmania
- Species : infantum
Evolves in two forms : cellular.
After staining MGG; it appears as an ovoid capsule 2 at 5 p in diameter with a core and a kinetoplast
The amastigote form : immobile, and is in the reticuloendothelial system in intra- or extracellular.
The promastigote forms : is moving, is found in the gut of the vector and in the culture medium, it is elongated 15 to 20p wide and is equipped with & rsquo; free anterior flagellum that allows it to move.
2- The vector :
Sandfly only the female bloodsucking adult evening picnic, ensuring the transmission of the disease.
The sandfly appears in summer giving a seasonal disease.
3- The reservoir :
Zoonotic form : with the dog as the main parasite tank ( Mediterranean Basin, Middle East, Brazil ).
Anthroponotic form : l & rsquo; man is the only source of infection for the vector (in; Sudan)
4- Cycle :
The sandfly is contaminated by pricking a vertebrate parasitized (dog, jackal, or man)
Once in his gut, the amastigote forms of Leishmania promastigotes change into multiplying and infecting making the sandfly.
A new blood meal ; sandfly reintroduced Leishmania in a healthy body and they will be phagocytosed by macrophages and can then parasitize the & rsquo; body.
The transmission can be done :
By contact with skin lesions d & rsquo; a noisy dog.
Blood transfusion or uncommon Transplacental
IV- EPIDEMIOLOGY :
In Algeria; VL has increased over 1981.
The most affected areas are the province of T1ZI-OUZOU, Bouira, Bejaia, Medea, Chelef Constantine, Setif, Jijel, Tlemcen, Oran, BISKRA, Tamanrasset.
VL reached the young child 1 at 4 years.
Common in rural areas where life is favored sandflies.
In the world; LV s & rsquo; & rsquo EVIT to; endemic in many tropical regions and warm temperate.
L & rsquo; incidence is estimated at 500.000 foot / the.
According to the & rsquo; WHO there have been in 57.000décés 1999 and 41000 in 2000.
Given the period of & rsquo; maximum activity of sandflies, cases are observed especially in late autumn and winter, but s & rsquo; & rsquo observe the whole, year.
V- CLINICAL STUDY :
A- Leishmaniose VISCERAL DU NOURRISSON :
1- Data interrogation :
Concept of & rsquo; living in area & rsquo; endemic.
Presence of a sick dog in the entourage with abnormal aging, emaciation, Skin lesions type depilation.
Canker inoculation : vesicular-papular lesion secondary fleeting to sandfly bite.
2- The beginning :
incubation; varies 6 weeks 6 month; may be shorter, after 10 at 14 days after the bite.
The beginning : insidious progressive, sometimes brutal, marked by fever , digestive disorders with AEG.
L & rsquo; clinical examination at this stage include a discrete SPM with abdominal distension.
3- The status stage :
The triad :
FEVER + pallor + hépato-splénomégalie
– Fever :
- crowds say
- the most constant sign,
- In the long term.
- Irregular varies from & rsquo; one moment to another, n & rsquo; is not influenced by antipyretics,
- The double daily febrile piç and temperature > 40°
- It yields only under specific treatment or steroids.
– Pale mucous cutaneous: reflecting intense anemia.
– the splénomégalie: voluminous painless firm moderate, mobile
– The hepatomegaly : quasiconstante, moderate, farm painless regular board
4- Other clinical signs :
Digestive disorders type of diarrhea with malabsorption leading to malnutrition. Edematous syndrome with ascites.
Jaundice with a hemorrhagic syndrome associated with thrombocytopenia.
Respiratory manifestations are frequent.
The leishmania nephritis is extremely rare, so that & rsquo; proteinuria is usually observed
B- paraclinical studies :
- FNS : pancytopénie
– Normochromic normocytic anemia (splenic sequestration, autohémolyse, bone marrow failure).
– Leukopenia with severe neutropenia.
– Sedimentation rate: faster than 50mm / 1st hour
– Protein electrophoresis: hypoalbuminemia, hyper major gammaglobulinémie.
- l’immunoélectrophorèse: increase of IgG with anode extension characteristic.
- Hypocholesterolemia and hypertriglyceridemia
positive in 90% cases :
ELISA, IFI (+1/80), test & rsquo; direct agglutination
The problem with these serological tests is the ability to cross-react with d & rsquo; other pathogens and the inability to distinguish between progressive disease or old infection +++
certainty exams :
a- L & rsquo; direct examination :
The bone marrow aspiration is the & rsquo; colorful key consideration MGG Form amastigote +++
The marrow can be rich, poor or normal.
Reaction histio monocytic and erythro blastosis.
Other collection sites: rate, foie , Jeju, ganglionic.
b- Culture :
Is made on culture medium NNN( New,Mac Neal,Nicolle) in rabbit blood.
On puncture MO. incubation at 25 ° C for 21 days.
+++ promastigote form
Interest culture :
the result of a negative direct examination
Typing enzymatic stem iso.
therapeutic test: In vitro drug sensitivity.
c- PCR : Chain polymerase reaction :
Detects the & rsquo; parasite DNA by amplification chain.
Negative if lysed parasites.
d- Le test leishmania nested PCR [ LnPCR) :
Diagnostic a monitoring you tired.
e- Search & rsquo; soluble antigens in urine :
specific 100% with sensitivity 47-100% in immunocompetent
f- montenegro reaction :
(intradermal reaction leishmanin) is a test that measures the cellular response to the & rsquo; leishmanian antigen.
The test is negative along the disease. 11 becomes and remains positive after TRT reflecting the restoration of the & rsquo; cellular immunity.
C- clinical forms :
F. aigues: rapidly evolving sudden onset.
F .chroniques: d & rsquo; slow evolution for several months usually little feverish.
F .apyrétiques: are very rare.
F .ictérique: hepatitis leishmania, compression bile by a ggl, hemolysis.
F .oculaire: keratitis, iritis, retinal hemorrhage.
F. with kidney disease: hematuria + proteinuria
F .associées: Tuberculosis, malaria, typhoid fever, hemoglobinopathies
WE- DIFFERENTIAL DIAGNOSIS :
brucellosis, Malaria, Leucoses, Histiocytoses X, lymphomas
VII- TREATMENT :
Symptomatic treatment :
Transfusion of packed red blood cell or platelet.
ATBpie if bacterial superinfection
Restoration of & rsquo; condition: correction of electrolyte disturbances and malnutrition.
specific treatment :
After improving the & rsquo; general condition and pretherapeutic : hepatic, renal, cardiac(ECG).
a- derivatives & rsquo; antimony : antimoniés pentavalents: the Glucantime:
Dosage : 20mg / kg / day in two progressive dose injections deep IM.
Presentation : 5 ml contains 425mg of & rsquo; antimony, is 85 mg & rsquo; pentavalent antimony / ml.
The total duration of 30 days or more 15 days after sterilization of the myelogram.
Side effects :
1- stibio-intolerance :
Impressive stopping treatment.
various rashes, myalgies, diarrhea and vomiting, bulbar syndrome is coughing coqluchoide, hyperthermia , tachycardia.
anaphylactic intolerance or release of toxic by massive lysis.
2- antimony intoxication :
Late, occurring at the end of TRT and even after stopping it, linked to overdose: kidney damage, myocardial ,hepatic , polyneuropathy , haematological
b- Amphotéricine B : fungizone used by IV infusion
strict monitoring of urea , creatinine , ECG
c- Amphotericine B liposomiale : Ambisome:
reduced renal toxicity, trt first line in Europe due to the short duration of & rsquo; hospital.
VIII- EVOLUTION :
At normal temperatures in 3-15j.
Condition: rapid recovery of weight and the & rsquo; appetite.
Haematological: gradual repair & rsquo; first thrombocytopenia, and the & rsquo; anemia, and leukopenia.
La rate: sometimes slow rapid regression, its disappearance takes several weeks or months. The hepatomegaly : evolution parallel to that of the spleen.
The protidic disturbances are much slower to correct the healing criteria Giraud :
Apyrexia for over 2 month.
Absence of parasites myelogram.
Positive reaction of Montenegro.
IX- aftermath :
fibrous spleen with hypersplenism.
Mild anemia with moderate neutropenia buffy.
Hypergammaglobulinaemia with persistent erythroblastosis.
X- PROPHYLAXIS :
Slaughter of stray dogs and sick.
Urbanization good conduct.
XI- Conclusion :
Serious illness up, for which effective specific TRT is an HPSM febrile infants must always think of the LV prevention is possible ensuring the eradication of LV and hydatid cyst
Courses of Dr. Bicha – Faculty of Constantine