Tissue parasites such as
2. Transmission forms
2.1. The life cycle of
Leishmania spp.: the vector transmission
Upon entering the host, the parasite first encounters a host immune reaction following activation of the complement system. With respect to this process, four distinct activation pathways have been identified: the classical pathway, the alternative pathway, the lectin pathway and the extrinsic pathway . In humans, the parasite can evade the immune response by inhibiting complement-mediated lysis, which occurs within the phagolysosomes of macrophages. This protective effect is conferred by the membrane protease gp63, or leishmanolysin, which inhibits attacks against the parasite cell membrane by adhering to complement components . Promastigote-stage parasites differentiate into small, round cells 3-5 µm in size that lack flagella, known as amastigotes. This form can be readily observed within host cells by microscopy, where they are referred to as Leishman-Donovan  bodies. Finally, when multiplication of the parasites exceeds the holding capacity of the phagocytic cell, cell lysis occurs, releasing the parasites to infect new cells.
By some conservative estimates, a vector might release between 1-1000 metacyclic promastigotes into the host during feeding [6-7]. However, other estimates based on molecular biology techniques indicate that a vector might release as many as 600 to 100,000 metacyclic promastigotes during a feeding period and that this number varies as function of feeding time. In addition, it is known that large numbers of parasites actually increase vector feeding time, as the parasites physically obstruct proper functioning of the proboscis . Therefore, based on these findings, between 100 and 100,000 metacyclic parasites are commonly used to inoculate the footpads or pinnae of animals in
2.2. Organ transplants, blood transfusions and hemodialysis
Therapeutic advances in a wide variety of medical fields have dramatically improved overall quality of life and life expectancy in modern societies. This has partly been achieved through the development of techniques such as organ transplantation, hemodialysis, and blood transfusion, which are particularly useful for the treatment of chronic disease. However, the transmission of infectious diseases during such procedures must account for and avoided. Furthermore, human migration can easily transport diseases transmitted by vectors from endemic locations to non-endemic locations, as often happens with protozoan parasites of the blood, such as
During organ transplantations, there are several possible ways in which microorganisms such as
Infrequent or atypical symptoms can cause delayed diagnosis of leishmaniasis. The primary clinical signs and symptoms related to
Blood volume loss or deficiencies in specific blood components are indicators that a transfusion of blood or blood-derivatives from a donor to a recipient may be necessary. Blood transfusions are frequently performed during or after surgical interventions, and in the case of leishmaniasis patients with a history of organ transplantation and blood transfusion, the disease is generally considered to be a complication of the transplantation process [15, 32-33]. In patients without such a background, infections are generally considered to have occurred through the transfusion of blood or blood-derived products. The first case of
In general, the causative agents of visceral leishmaniasis belong to the
Among other notable cases of secondary leishmaniasis due to blood products and transfusions, there was the case of a patient with an autoimmune disease, idiopathic thrombocytopenic purpura. The patient was transfused with concentrated platelets on multiple occasions over the 2-3 year period prior to the development of leishmaniasis, a diagnosis that was confirmed by bone marrow aspiration .
Another case involved an infant who received a blood transfusion within 7 days of birth due to integument pallor with a subsequent diagnosis of myelofibrosis. The blood donor was a relative who died three months after the donation, after developing hepatosplenomegaly, pyrexia and a fever of unknown origin; the diagnosis was made
In a case involving an elderly patient, a 77-year-old woman with a history of chronic atrial fibrillation, hypertension and chronic kidney disease with hemodialysis treatment underwent surgery due to cholecystitis, during which time she received two units of blood. A month and a half later, she presented with fever, diaphoresis and chills during a hemodialysis session and over the next 24 hours; she also showed occasional diarrhea and weight loss. These symptoms did not improve despite treatment with antibiotics. In the intensive care unit following hemodialysis, the patient showed thrombocytopenia and hypotension with good ventricular systolic function, requiring volume recovery and vasopressor therapy; hydrocortisone was also included in the treatment. A bone marrow aspirate confirmed the presence of intracellular amastigotes and numerous extracellular promastigotes, although these were not observed in the peripheral blood. Treatment with Amphotericin B increased her platelet numbers, although hemodynamic deterioration continued until the patient’s death. Cultures begun previous to death showed the presence of
Seven U.S. military groups assigned to Operation Desert Storm in the 1990s developed atypical clinical presentations of
There have also been various clinical studies carried out on individuals attending blood banks in which the presence of the parasite was assessed for using techniques such as ELISA (enzyme-linked immunosorbent assay) , IFAT , Western blotting, culturing and PCR [44-45]. ELISA experiments showed that 2.4% of the individuals had
Furthermore, questioning may be insufficient to exclude donors that have visited endemic areas within the last 12 months or that have had clinical diagnoses of leishmaniasis, as recommended by the WHO publication
In cutaneous species, such as those belonging to the
In individuals with chronic kidney disease, hemodialysis is a therapy that can greatly improve patient prognosis and prolong and improve their quality of life. However, like many other therapeutic procedures, hemodialysis can have adverse effects, including bacteremia and sepsis due to poor aseptic techniques during treatment . Indeed, it has been documented that if proper care is not taken to sterilize hemodialysis equipment, including the cleaning and replacement of disposable parts, there is high risk of acquiring infectious/contagious diseases , including parasitic infections. Unlike with the situation with
2.3. Sexual transmission
2.3.1. Leishmaniasis in sexual organs in humans
Cases of leishmaniasis of the sexual organs have been reported, manifesting as lesions on the genitals, and such cases have been reported in both humans [52-56] and in animals [57-58]. Three possible mechanisms for the development of leishmaniasis of the sexual organs and genitals have been suggested: (1) local infection derived from a wider systemic infection; (2) infection due to exposure of the genitals to a vector in an endemic area; and (3) infection due to direct contact of the genitals with an ulcerated lesion during intercourse .
By questioning patients, such cases of genital leishmaniasis in humans could not always be directly linked to either intercourse [52-53] or to sleeping naked in endemic areas . However, in cases where the lesions were observed on the vulvar regions , direct vector-mediated infection can be ruled out, leaving open the possibility for localized infection of systemic origin or from intercourse with a previously infected individual.
It should be noted that genital ulcers can have numerous causes, and thorough diagnoses should be conducted in all cases to avoid confusion with other diseases, such as squamous cell carcinoma or primary syphilis . Likewise, the presence of other types of infectious microorganisms should also be ruled out .
2.3.2. Leishmaniasis in sexual organs in animals
Among animals, domestic dogs are considered to be the main reservoir of
It has been observed that when
2.4. Congenital transmission
2.4.1. Congenital leishmaniasis in humans
Vertical transmission is defined as the congenital transmission of a pathogenic microorganism, condition, or characteristic from one generation to the next via the placenta, hematogenous, the birth canal, or nursing at the maternal breast . Vertical transmission has been demonstrated for visceral leishmaniasis caused by
The epidemiological antecedents of leishmaniasis are crucial when pediatric patients or those of childbearing age develop symptoms suggestive of leishmaniasis. A mother who was diagnosed with
In Germany, there have been two reported cases of leishmaniasis involving mothers who visited endemic zones prior to their pregnancies. The first case involved a 16-month-old pediatric patient with visceral leishmaniasis whose mother had traveled to endemic zones two years earlier . The second case was a 15-month-old child with visceral leishmaniasis whose mother was on a farm in an endemic zone between 20 and 22 weeks of pregnancy .
Chronic visceral leishmaniasis has been linked to premature birth and materno-fetal deaths.  A histological analysis of the placenta and an aspirate of the lymphatic ganglion revealed the presence of thrombotic, vascular changes in the placenta of a fetus at five months of gestation in a mother that had been infected with leishmaniasis for two months . Neonates carried to term from infected mothers have remained asymptomatic during the first weeks or months of life. However, Leishman bodies have ultimately been detected in the bone marrow, and anti-
Leishmaniasis can be accompanied by concomitant infections by organisms from similar genera. During the second trimester, a pregnant patient was initially treated for leishmaniasis and showed improvement at 30 days. The baby was born vaginally at 36 weeks without complications and weighed 1,700 grams. He was readmitted three days later for deterioration due to probable malaria and tuberculosis, but he did not show improvement following treatment. Amastigotes were detected in an aspirate of the lymphatic ganglion of the mother. In addition, IgG antibodies were detected in the baby; these antibodies were attributed to passive transplacental transfer of parasite-specific antibodies from the mother to the fetus, negating the need for treatment. He was admitted once more at seven months old for symptoms suggestive of
Individuals, whether mother or offspring, in endemic zones can be infected for months or years prior to the onset of symptoms. For example, a woman visited an endemic zone and became pregnant two years later. She did not experience any symptoms during her pregnancy or post-partum while in the non-endemic zone nor was there evidence of the existence of the vector in the geographic area. While the mother remained asymptomatic, the infant exhibited symptoms of possible visceral leishmaniasis, which was confirmed by various laboratory tests .
There is evidence that cutaneous leishmaniasis is associated with perinatal health problems, as has been observed in Brazil, where women with
2.4.2. Congenital leishmaniasis in animals
In Brazil, a trial was performed with asymptomatic and symptomatic mixed-breed dogs that were infected with
2.4.3. Experimental models of congenital transmission
In a murine model of visceral leishmaniasis, twenty 12-week -old female BALB/c mice were infected with
In experimental model in which hamsters were infected with 106 parasites/mL of
2.5. Other factors related to substance abuse and work environment
2.5.1. Drug use
In cases of leishmaniasis infection due to fomites, such as sharp, contaminated objects, the most vulnerable population are illicit drug users. In a Spanish study of syringes used for recreational drug use, it was reported that 32-52% of the syringes were contaminated by
2.5.2. Work environment transmission
As described above,
According to the CDC, the
Taken together, there is a clear need for the health system to reevaluate the global situation concerning leishmaniasis transmission and to implement strategies to reduce the exposure of individuals to
Financial support: The chapter was sponsored by Instituto Nacional de Perinatologia (212250-22701). Primary investigator: Dr. Norma Galindo-Sevilla.
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