As mentioned above, the pathogen is transmitted by female mosquitoes. During a bite, from 100 to 1000 pathogens enter the human body along with saliva. Leishmania has a specific ability - they freely penetrate macrophages without provoking an immune reaction. In them they are transformed into an intracellular form and begin to actively multiply, provoking pathological reactions from internal organs 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 is worth noting that the disease is characterized by seasonality. It is most often diagnosed between May and November. Such time frames are determined by the life activity of mosquitoes.

Classification

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

The symptoms of the disease directly depend on the form that has begun to progress in a person. It is important to immediately contact your doctor at the first sign of leishmaniasis. medical institution for diagnosis and treatment of the disease.

Clinic of visceral leishmaniasis

Due to the long incubation period, not many patients can associate the progression of visceral leishmaniasis with a mosquito bite. This makes diagnosis somewhat difficult. The first signs of visceral leishmaniasis may appear only six months after the pathogen enters the body. The patient exhibits the following symptoms:

• malaise;
• lethargy;
• fatigue;
• weakness;
• decreased appetite;
• hyperthermia up to 40 degrees;
• there is a color change skin. It acquires a grayish tint, and in some cases hemorrhages appear on it;
• minor . However, they are not painful and do not adhere to each other.

The first sign of 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).

Characteristic and constant symptom pathology is . It is the spleen that increases in size more quickly. Already in the first month, its size can be so large that the organ will occupy the entire left side belly. As visceral leishmaniasis progresses, both organs become dense, but when palpated painful sensations does not arise. An enlarged liver is fraught with dangerous consequences, up to and .

Cutaneous leishmaniasis clinic

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

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

Primary leishmanioma develops in three stages:

• tubercle stage. A papule forms on the skin and grows quickly. 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, exposing the bottom with weeping. First highlighted serous exudate, 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.

With the progression of sequential leishmanioma, around primary focus Several other secondary nodules form. Tuberculoid leishmaniasis manifests itself at the site of a formed primary leishmanioma or at the site of a 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.

A special form of cutaneous leishmaniasis is espundia. Symptoms of the pathology appear gradually. Against the background of existing skin lesions, extensive ulcers appear. This is most often observed on the extremities. Gradually, the pathogen penetrates the mucous membrane of the pharynx, cheeks, larynx and nose, where it provokes purulent-necrotic changes.

Diagnostics

An infectious disease specialist diagnoses leishmaniasis. Clinical diagnosis is made based on characteristic clinical picture, as well as epidemiological data. To confirm the presence of cutaneous or visceral leishmaniasis, the following diagnostic methods are used:

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

Treatment

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

For the visceral form, the treatment plan includes the following drugs:

• Pentostam;
• Glucantim;
• Solyusurmin.

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

If conservative treatment turned out to be ineffective and the patient’s condition has not stabilized, then surgery- the spleen is removed. For skin forms of the disease, they also resort to physiotherapeutic treatment - they warm up the skin and conduct ultraviolet radiation.

Prevention

In order not to treat the pathology, you should start preventing it as early as possible. To protect yourself from mosquito bites, you must use individual means protection from insects. Also for the purpose of prevention in areas with high risk infection, it is necessary to disinfect living quarters and install mosquito nets on windows.

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Diseases with similar symptoms:

Carbuncle is a disease inflammatory in nature which amazes hair follicles, sebaceous glands as well as 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 possible.

What is Visceral Leishmaniasis

Visceral leishmaniasis(visceral leishmaniasis, Dum-Dum fever, kala-azar) - transmissible parasitic disease, characterized chronic course, undulating fever, hepatosplenomegaly, pancytopenia.

There are Indian kala-azar, Mediterranean visceral leishmaniasis (childhood), East African and South American visceral leishmaniasis.

What causes Visceral leishmaniasis

Visceral leishmaniasis occurs in countries with subtropical and tropical climates. In the CIS countries (Central Asia, Transcaucasia and Southern Kazakhstan), sporadic cases of Mediterranean visceral leishmaniasis are recorded.

Mediterranean visceral leishmaniasis is a zoonosis. Its reservoir and source in cities are dogs, in rural areas - dogs, jackals, foxes, rodents. Leishmania carriers are mosquitoes, the females of which feed on blood, attacking humans at dusk and at night and infecting them through a bite. Mostly children aged 1 to 5 years are affected. The infection season is summer, and the morbidity season is autumn of the same year or spring of the next year.

Pathogenesis (what happens?) during Visceral leishmaniasis

Leishmania invades the cells of the bone marrow and reticuloendothelial system.

Symptoms of Visceral Leishmaniasis

The clinical picture of Indian and Mediterranean visceral leishmaniasis is similar. Incubation period ranges from 20 days to 10 - 12 months. In children, the primary affect (papule) occurs long before common manifestations diseases. In the initial period of the disease, weakness, loss of appetite, adynamia, and a slight enlargement of the spleen are noted. The period of the height of the disease begins with a fever, the duration of which ranges from several days to several months. Temperature rises to 39 - 40 0C are replaced by remissions.

Constant signs of visceral leishmaniasis are enlargement and hardening of the liver and spleen, and lymph nodes. In the first 3–6 months of the disease, the spleen enlarges at a rapid pace, then more slowly. Palpation of the liver, spleen, and lymph nodes is painless. Bone marrow damage and hypersplenism lead to severe anemia, as evidenced by pallor of the skin, which sometimes takes on a “porcelain”, waxy or earthy tint. Patients lose weight sharply, they develop ascites, peripheral edema, and diarrhea. Characteristic hemorrhagic syndrome with hemorrhages in the skin and mucous membranes, nosebleeds, gastrointestinal tract, necrosis of the tonsils, mucous membranes of the mouth, and gums.

Due to the enlargement of the liver, spleen and high position of the diaphragm, the heart shifts to the right, constant tachycardia is determined, and blood pressure decreases. Pneumonia caused by secondary flora often develops. In the terminal period of the disease, cachexia develops, muscle tone sharply decreases, the skin becomes thinner, through abdominal wall the contours of a huge spleen and large liver often appear. The hemogram contains characteristic features: sharp decline the number of erythrocytes, leukocytes (especially neutrophils), eosinophils, platelets. ESR is sharply increased (90 mm/h).

Complications of visceral leishmaniasis- pneumonia, enterocolitis, nephritis, thrombo-hemorrhagic syndrome, laryngeal edema, ulcerative stomatitis, noma.

Diagnosis of Visceral Leishmaniasis

Treatment of Visceral Leishmaniasis

Etiotropic drugs for the treatment of visceral leishmaniasis are antimony preparations, which are administered parenterally (intravenously, intramuscularly). They use a 20% solution of solyusurmin (Russia), glucantin (France), neostibazan (Germany), pentostam (England). Convalescents are monitored for 4 months (possibility of relapses!). At bacterial complications Antibiotics are indicated; in case of pronounced changes in the blood, transfusions of blood, leuko- and red blood cells are indicated.

Prevention of Visceral Leishmaniasis

Sanitation of dogs with leishmaniasis, fight against mosquitoes, protection from mosquito attacks, use of repellents.

Which doctors should you contact if you have Visceral Leishmaniasis?

Infectious disease specialist

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Visceral leishmaniasis – infectious disease, usually found exclusively in hot climates. The visceral form is the most severe manifestation of the disease, and today infection in developed countries It is diagnosed quite rarely, epidemics do not occur. However, people with extreme low immunity and those who travel on vacation or work to the southern tropical countries, it is worth knowing how this disease can manifest itself, what it is, what diagnostics and therapy are required.

Features of the disease

According to ICD-10 of this disease code B55.0. The infection today belongs to the category of forgotten - this means that it is found mainly in undeveloped countries, for example, on the African continent.

The geographical distribution of leishmaniasis is predominantly tropical countries (hot climate). It is almost impossible to encounter this infection in other places. For example, cases of infection today are still found in Central Asia, Transcaucasia, and Southern Kazakhstan, and the type of infection depends on the location.

Anyone who lives or plans to visit such regions should know about visceral leishmaniasis. On at the moment There are many different infections that are found exclusively in tropical climates, some of which are deadly.

Important! If you feel suddenly unwell while in an unfamiliar environment or after returning from a vacation or business trip, you should immediately consult a doctor to make sure there are no serious infections.

It is worth knowing about the main carriers of this infection. Usually a person becomes infected with the disease from various animals. IN tropical forests Mosquitoes and other blood-sucking insects are often the main vectors of leishmaniasis. In general, they quite often spread various infections, which can even lead to death.

Various stray animals, for example dogs and some, can also be carriers of this disease. wild animals. These vectors are most often found in cities. Leishmaniasis infection usually occurs through a bite. However, in any case, you should not come into contact with unfamiliar animals. This disease is not usually transmitted from person to person.

Important! It is also worth noting that the worse the immunity, the higher the likelihood of developing a severe form of leishmaniasis. HIV-infected people are more likely to develop visceral form infections are much higher. Therefore, people with reduced immunity need to be more attentive to themselves and their condition.

When this infection occurs, many severe symptoms, but they are not characteristic. To make a correct diagnosis, you need to collect anamnesis, take necessary tests, which will not allow this disease to be confused with any other bacterial or viral infections.

What organs are affected by visceral leishmaniasis? The infection attacks first spinal cord and nervous system, but manifestations usually occur in some organs digestive tract. Leishmaniasis also affects the condition of the liver and spleen.

Usually between different types lesions there is no particular difference in the development of symptoms. The incubation period for this disease usually ranges from 10 days to several months, depending on the overall health of the person. The invasive stage can be quite long, so it is not always possible to immediately establish the exact cause of development this state and the occurrence of infection. Visceral leishmaniasis develops along the following path:

These are the main symptoms of leishmaniasis. Similar symptoms can appear with other infections and other diseases, so if these signs are detected, you should consult a doctor and undergo the necessary examination.

Important! In children, the papule begins to develop earlier than other symptoms, so it is worth remembering the difference in the occurrence of symptoms in children and adults.

Diagnostics

Diagnosis of this vector-borne infection usually complex: it is important to correctly identify the causative agent of fever and other symptoms and make sure that the disease is not caused by other microorganisms, and identify complications of the pathology.

Visceral leishmaniasis can lead to the development of multiple dangerous complications. Most often, pneumonia occurs; hemorrhagic syndrome, enterocolitis, stomatitis, and laryngeal edema are possible. Usually these diseases are not fatal, but in an advanced state without timely treatment they can lead to fatal malfunctions for the body.

Treatment

Treatment of “black fever” (one of the names of the infection) can be carried out exclusively by an infectious disease specialist, usually in a hospital setting and quarantine. The main therapy is carried out using antimony drugs - they are administered intravenously and intramuscularly. There are many drugs of this type, they help to quickly suppress the infection.

It is impossible to get vaccinated against leishmaniasis; the only method of prevention is to avoid attacks by mosquitoes and other living creatures that live in places where this infection is spread. You should also avoid contact with unfamiliar pets, as even dogs can spread Leishmania. Should be used against mosquitoes special means– repellents.

The incubation period of visceral leishmaniasis can be from 2 weeks to 1 year or more, but on average it is 3-5 months, so cases of the disease are recorded all year round, with a predominance in the winter and spring months. Often in children under 1.5 years old, a primary affect can be detected at the site of a mosquito bite - a small pale pink nodule. The disease visceral leishmaniasis is characterized by gradual development intermittent fever. Another symptom of visceral leishmaniasis is splenomegaly: the spleen enlarges quickly and evenly, and the liver, as a rule, less intensely. Sometimes there is an increase peripheral lymph nodes. Characteristic features visceral leishmaniasis are also: progressive anemia, leukopenia, thrombocytopenia, hyper- and dysproteinemia, increase in ESR, increasing exhaustion, hemorrhagic syndrome. Complications usually arise associated with the addition of a secondary infection. In young children everything clinical manifestations occur more acutely, in adults the disease visceral leishmaniasis often occurs chronically; The duration of the disease ranges from 3 months to 1 year, less often up to 1.5-3 years. In some infected people, mainly adults, visceral leishmaniasis has a subclinical course and can manifest itself after 2-3 years or even 10-20 years when exposed to provoking factors (HIV infection, etc.).

Visceral leishmaniasis, as an AIDS-associated invasion, has one important, fundamental difference from other opportunistic invasions (infections), namely: it is non-contagious, i.e. is not transmitted directly from the source (animals, humans) of invasion to humans. In the countries of Southern Europe in the early 90s of the last century, 25-70% of cases of visceral leishmaniasis in adults were associated with HIV infection, and 1.5-9% of AIDS patients suffered from VL. Of the 692 co-infection cases recorded, about 60% occurred in Italy and France. The vast majority of co-infection cases (90%) occurred in men aged 20-40 years.

In Russia, the first case of VL/HIV co-infection was diagnosed in 1991.

Visceral leishmaniasis (synonym: anaemia splenica infantum, internal leishmaniasis, infantile leishmaniasis, kala-azar) is one of the vector-borne tropical diseases and occurs between 45° N. w. and 30° S. w. According to 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 temperate and continental climates (hot and dry summers). ).

E epidemiology. Kala-azar is an anthroponosis; its causative agent is Leishmania donovani Laveran et Mesni], 1903, carriers are mosquitoes from the subgenus Laroussius, in India - Ph. argentipes, in Eastern 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, mainly under 30 years of age, are affected.

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

Immunity. In visceral leishmaniasis, both natural and acquired immunity appear to be observed. Repeated diseases are not noted. Manson-Bahr (R. E. S. Manson-Bahr) proposed an intradermal leishmanin test, which, like the tuberculin test, consists of intradermal injection of 0.1-0.2 ml of antigen containing 6-10 million killed leptomonads from a culture grown on the NNN environment (Ncolle, Novy, Mac Neal). Hardening of this area of ​​skin after 72 hours indicates 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. or more, usually 3-5 months. The temperature rises gradually and very rarely suddenly after a chill. The characteristic wave-like (undulating) type of temperature curve is characteristic (Fig. 3). When measuring your temperature every two hours, you often notice its fluctuations throughout the day. The skin acquires a peculiar color, in India it is dark, almost black (kala-azar - black disease). Dark coloration of the skin is explained by 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 swelling is observed, more often lower limbs, sometimes the eyelids, face and whole body, which are dystrophic in nature. Patients lose weight, and cachexia sometimes develops. The abdomen appears enlarged due to the spleen and liver (“frog” appearance). Lymph nodes increase, periadenitis is not observed. In advanced cases, a cardiac impulse is observed in the IV (less often 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 position of the diaphragm.

Rice. 3. Undulating (wavy) temperature curve in visceral leishmaniasis.

Rice. 4. ECG of a 6-year-old child with visceral leishmaniasis.

Heart sounds are usually muffled. With severe anemia, murmurs caused by anemia are heard over the heart. 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 myocardial dystrophy of a transient nature. Characteristic decrease blood pressure. On the part of the respiratory system, tachypnea and inflammatory complications due to secondary, predominantly coccal, infections (bronchitis and bronchopneumonia) are observed.

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

Splenohepatic syndrome is expressed in all patients, but with varying intensity. In leishmanial splenomegaly, the spleen is somewhat elastic, its surface is smooth, and 1 to 4 notches are noticeable on the medial edge. Intestinal disorders are observed (enteritis - more often, enterocolitis and colitis - less often). The recovery period is characterized by bulimia. In advanced cases, hyposthenuria is common.

From the outside nervous system are noted functional disorders such as neurasthenia and vegetative dystonia.

Characteristic is the presence of anemia, leukopenia with a tendency to agranulocytosis, and these phenomena are more pronounced when the disease is 2 months old. and more. In the bone marrow punctate there are the so-called Botkin-Gumprecht bodies, proerythroblasts, erythrocytes with basophilic granulation and fragments of the cytoplasm of endothelial cells, often containing leishmania (there are more of the latter in the splenic punctate than in 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 amount of these elements is below normal. Thrombopenia is noted. 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, necrotic and gangrenous processes with severe leukopenia and complete agranulocytosis are observed in the oral cavity on the tonsils, mucous membrane of the cheeks, and sometimes gums. In the bone marrow there is a myeloid reaction with inhibition of eosin-phylo- and megakaryocytopoiesis.

In kala-azar, leishmania is often found in the peripheral blood; in the Mediterranean form, it is very rare.

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

Napier's formol reaction technique. To 1 ml of blood serum placed in an agglutination tube, add a drop of 40% formalin solution; when the disease is 3-4 months old. and more after 1-2 minutes. The mixture hardens, and after 3-20 minutes. completely coagulates and takes the form of the white of a hard-boiled egg. Chopra's antimony reaction technique. Blood serum is mixed with saline solution table salt 1:10; to 1 ml of this mixture add 1 ml of a 4% solution of solusurin or another freshly prepared antimony preparation; in positive cases, turbidity appears, and then a white precipitate. Brahmahari distilled water reaction technique. 1 ml of serum is poured into distilled water (2 ml); in positive cases, turbidity and sediment are formed. These reactions become positive in patients with a disease duration of at least 2 months. RSK are not entirely reliable. For 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. Expressed diseases Without specific treatment, they usually end in death. At proper treatment In untreated cases, almost all patients can be cured; in some cases, the disease takes an abortive course and ends in spontaneous recovery.

Treatment. Solyusurmin is used ( sodium salt 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 with double distilled water; sterilize at t° 100° for no more than 30 minutes.

Injections of the drug are performed daily, 1 time per day. The course of treatment consists of 15-30 injections, rarely more. Depending on tolerability, 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 - full dose. If tolerance is poor, take a 1-2-day break and reduce the dose, and then increase it again.

With accompanying inflammatory processes apply antibacterial drugs(sulfonamides, antibiotics). Along with specific treatment use symptomatic remedies (calcium chloride, vitamins, antianemic drugs, tonic and stimulants, etc.).

Cure rates - improvement general condition patients, the disappearance of leishmania in the bone marrow, a decrease in ROE, a sharp decrease in the size of the spleen and liver. An important criterion for relapse-free cure should be the normalization of the leukocyte blood picture, a persistent increase in the absolute number of neutrophils to age norm. During the period of convalescence, a transient phase of eosinophilia of 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.

Kala-azar and its geographical variants are much easier to treat with antimonials and diamidines. After healing, cutaneous leishmanoids appear on the skin.

The Mediterranean form is resistant to these drugs.

Prevention. Complex 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 that carry leishmania.