Visit Report: Leishmaniasis and the study of the sandfly

target audience :
Aspect 1 : Studying the sandfly
Aspect 2 : Leishmaniasis
Not so long ago we visited the national history museum which is an archive of millions of different
species of wildlife and plants. Our visit was mainly focused on etymology and taxonomy. We looked at
the sand fly and the disease it transmits : leishmaniasis. The significance of my aspects to the museum I
visited is that scientists at the Natural History Museum are studying sandflies and leishmaniasis as part
of a five-year project called EDEN with scientists from 24 countries all around the globe. What they
are aiming to achieve is a better understanding of the fly and the disease and maybe as a fruit of their
efforts, devise a way to combat the disease.
What are the implications?
There are implications with both of these aspects. Economically studying the fly is expensive as
scientists have to make regular trips to France where they have to capture the flies and transport them
back to the UK. They also need equipment and in cases, medication. All this does not come for free,
neither is it cheap. Ethically, restrictions do not allow them to take live samples of the flies back to the
UK. Therefore they have to be killed, neither can they expose a living animal to the flies to see what
parts of the body fly likes to bite or what types of animal it favours.
The disease itself has numerous implications. The first is economic as the treatment is costly and
lengthy. Medicine is administered intravenously for up to 28 days. Also socially, the disease could
potentially wreck communities. The fact that it affects the aesthetic features which make an individual
stand out cause problems. Neglect and fear within the community would definitely be a massive social
issue.
MAIN ASPECT : Leishmaniasis
Overview
Leishmaniasis is a parasitic disease found in humans, dogs and some other animals. It affects 12
million peoples in 88 countires, mostly in tropical regions. Furthermore 350 millions are at risk from
the disease. The disease is spread by the sandfly. In humans the disease exists in two forms cutaneous
and visceral, with cutaneous leishmaniasis being the most common. It is found in 50-70% of the cases.

(1) Skin ulcers in cutaneous leishmaniasis

(2) Distended belly in visceral leishmaniasis

The difference between the two is that cutaneous leishmaniasis attacks the skin and mucus membranes

causing ulcers and lesions while visceral leishmaniasis affects internal organs causing the swelling that
is seen in the picture above. Visceral leishmaniases is more deadly as it has a mortality rate exceeding
90% if left untreated. Patients lose weight and in most cases, die. However that said, the lesions caused
by cutaneous leishmaniasis can be left to heal but the scarring is extremely severe.
How is it transmitted?

(3)
Diagram showing the transmission of leishmaniasis
. As the sandfly takes a blood meal, promastigotes of the leishmanial parasite enter the human host via
the proboscis. (3) The promastigotes it injects are phagocytised by macrophages (engulfed by white
blood cells). The promastigotes inoculated by the sandfly vector enter macrophages where they
transform into amastigotes before multiplying.The parasite occurs in the amastigote form in the
vertebrate host and in the promastigote form in the sandfly vector and on culture. Inside the white
blood cells the amastigotes multiply and the cell eventually bursts. At this point the symptoms begin to
show as the amastigotes begin to attack parts of the body or the skin. Infection and multiplication in
cells of the monocyte/macrophage line leads to generalized lymphadenopathy and splenomegaly.

(8)
Sand fly taking a blood meal and infecting a host.
So What Are The Risk Factors?
Leishmaniasis as has many risk factors, and some may not be as apparent as others as 350 million
(9)people are at potential risk. A massive 5% of the total world population. A big risk factor is
obviously living in an area where the vector (sandfly) s a problem. But a huge risk factor that is the
main concern of medical experts is AIDS and the immuno-suppressed (malnutrition) as they are more
susceptible to infection. And in the unfortunate event that they are infected, the disease can leave them
too weak to fight any infection or inevitably dead. These people are 100-1000 times more at risk of
getting the disease.
Another risk factor is age, as children and the elderly are more likely to be affected and damaged more
by the disease.
Incomplete therapy of the disease may result in recurrence
Where is it a problem?
As mentioned earlier leishmaniasis is endemic in 4 continents and in 88 countries. And with global
warming, favourable conditions for its vector (sand fly) are becoming even more widespread,
meaning the sandfly and the disease can only spread and invade more countries. 90% of the
cases of leishmaniasis occur in Bangladesh and it is also becoming a rising problem in Iraq, as
the troops involved in the recent conflicts are also getting affected by the disease.

(4)
This map shows the distribution of cutaneous leishmaniasis through out the globe. It is most
common in the tropics where the temperatures favour the vector (sandfly). It is evident the
South-America has the largest single distribution of the disease with large concentrated
scatterings in Africa, Europe and Asia.

(4)
This map now shows the distribution of visceral leishmaniasis.It is still predominantly tropical
however more widespread. Here it is also pretty much the same story where South-America
Has the single largest concentration of the disease with fairly concentrated scatterings of the
disease in Europe, Africa and asia.
Lets zoom in: What causes this disease?

Leishmaniasis itself is caused by a protozoan micro-organism. Its in retrospect a very tiny

organism, with a single-cell. It is a parasite and needs the right host. And humans just happen
to be the right host for the organism to multiply in.

(8)
(5)A magnified image of the protozoan organisms and a white blood cell.
Scientifically the cause is known as intracellular protozoan parasites of the genus
Leishmania(6)
In human tissue, leishmanial parasitic protozoans occur as amastigotes that multiply within
histiocytes or macrophages. Amastigotes are ovoid or round and measure in at around 1.5-3
m in diameter (up to 5 m in smears). They have a thin cell membrane, large nucleus, and a
rod-shaped kinetoplast that is not always visible in tissue sections because of the orientation of
the parasite.
Symptoms
Symptoms vary with disease (visceral) . This makes diagnosis difficult. In visceral
leishmaniasis there is a systemic infection so the symptoms cover a wide circle of potential
disease. However cutaneous leishmaniasis has the distinct lesions and inflammation of the
mucus membranes. Here are some of the symptoms:
Visceral : (14)

Fever
Weight loss
Enlarged spleen
Enlarged liver
Swollen glands
Bone marrow symptoms
Low blood counts
Anaemia
Low white blood cell count
Low platelet count
Cutaneous (14)

Skin sores
Raised edge sores - like a volcano with a central crater
Scabs
Swollen glands
Swollen underarm glands

How is it treated?
Leishmaniasis is very difficult to treat. This is because of its non-specific symptoms and the lack of an
effective simple way to treat it.
Most patients with leishmaniasis do not need hospitalization during treatment.
The drug of choice is sodium stibogluconate and it is administered over a period of
20 days for cutaneous leishmaniasis and 28 days for visceral leishmaniasis. Administered
intravenously, it is not the easiest treatment, neither is it fast enough. However recent breakthroughs
have made it possible for an oral treatment, thought how many times this needs to be taken and its cost
is still unknown., there is hope for better treatment. the drug itself has side effects as it is phlebotoxic.
After a few doses it becomes increasingly difficult to find a vein in which to inject the drug. It can also
cause a reduced appetite, nausea, vomiting, diarrhoea, headache, tiredness, joint pains, muscle aches,
dizziness, and anaphylaxis.
In advanced stages of the disease, arsenic compounds in glycerine can be administered, but this is
extremely painful and fatal for the patients too.

Direct injection is the easiest form of treatment, also

painful and its benefits do not supersede IV treatment where the drug is administered in small amounts
along with a fluid over a long period. Intra-muscular treatment is possible but this is too painful.
Can the disease be controlled?
Controlling its vector s the only way to control the disease. However firstly the fly is very difficult to
distinguish as it resembles midges and black flies, which are all referred to as sandflies. then theres
the fact that most effective insecticides have undesirable environmental and human effects. Then
theres the economical problems associated with this, therefore control is possible, but not easy.
Any future developments?
The future developments of studying the disease are pretty obvious. Scientist are striving for an
effective way to combat these tiny protozoan organisms. So an effective treatment and if possible a
cure is what scientists are focused on. And with the rapid acceleration of 21st century science and
development, this could happen at any time.
Reference List
references,
(1) http://www3.baylor.edu/~Charles_Kemp/hand.jpg
(2) http://www.icp.ucl.ac.be/~opperd/parasites/images/WHO1.jpg Last updated: 22 October 1997.
(3) http://en.wikipedia.org/wiki/Image:Leishmania_LifeCycle.gif
(4) http://www.vacunasaep.org/imagen/mapa_leishmaniasis_visceral.jpg

(5) http://www.internetmedicin.se/images/uploads/Leishmaniasis-tropica,-amas.jpg
(6) http://www.leishmaniasis.info/
(7) Gossage S M, Rogers M E & Bates P A (2003) Two separate growth phases during the development
of Leishmania in sand flies: implications for understanding the life cycle. Int J Parasitol. 33, 10271034.
(8)http://www.afip.org/Departments/infectious/lm/05.html
(9) national history museum leishmaniasis journal
(10) http://www.nlm.nih.gov/medlineplus/ency/article/001386.htm Update Date: 3/6/2006
(11) http://www.who.int/tdr/diseases/leish/lifecycle.htm
(12) http://www.leishmaniasis.info/
(13) Azadeh B, Samad A, Ardehali S. Histological spectrum of cutaneous leishmaniasis due to
Leishmania tropica. Trans R Soc Trop Med Hyg 1985;79:631-636
(14) http://www.wrongdiagnosis.com/l/leishmaniasis/symptoms.htm
Evaluating sources.
I was careful with internet sources as the internet can be misleading. Where I chose to get my images, I
also got my information from too. The strongest sources with the most accurate information I feel were
the national history museum journal, the WHO website, The growth phases book, the ICP website, the
Internet medicine and the histological spectrum of cutaneous leishmaniasis book. The websites are
monitored by professionals with no access to anybody else. The NLM website is also very reliable as it
is updated everyday. The book also was written by 3 professionals, I took interest with the growth
phases book as it took the disease to a tinier level, which had good accurate information. However my
other sources, namely wikipeida are fairly unreliable as anyone has access to them. These sites were all
relevant to the biology I was discussing because they had the information I needed. The
leishmaniasis.info site was based around canines which proved a bit of an obstacle so I could not fully
trust the information as my work was centred around humans.