Leishmaniasis in Emergency Medicine Workup

  • Author: Jennifer J Lee, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Aug 16, 2010
 

Laboratory Studies

  • Cutaneous leishmaniasis
    • Diagnosis usually is based on the appearance of the lesion.
    • In more than 70% of cutaneous leishmaniasis cases, microscopy of the parasite in Giemsa stains or histological section can reveal the parasite and should be attempted first. Culture of the organisms is an option but is unreliable (approximately 40% sensitivity) because organisms are difficult to isolate from the lesion, especially as the lesion becomes older. The organism grows on Schneider Drosophila medium (positive results in 1 wk) and Novy-MacNeal-Nicolle (NNN) medium (media available from the CDC). Cultures can produce positive results in 1-3 weeks.
    • The leishmaniasis skin test (Montenegro test) produces positive results 3 months after the appearance of lesions. The Montenegro test is performed by injecting killed promastigotes intradermally and examining the skin 48 hours later to see if a delayed-type hypersensitivity response has formed. A positive result is defined as induration of 5 mm or more. The two main drawbacks are that acute infections cannot be identified (in endemic regions, more than 70% of the population will test positive) since it remains positive for life and those who are immunosuppressed may not mount a response.
    • Serologic tests such as isoenzyme or monoclonal antibody analysis are not well established. However, polymerase chain reaction (PCR) is being used more frequently and is more accurate in determining new-onset leishmaniasis than serum tests.
  • Mucocutaneous leishmaniasis
    • Diagnosis preferably is made by culture of the organism, but organisms are often scant.
    • On biopsy, a nonspecific granulomatous reaction often is observed. Giemsa stain may show the organisms.
    • Results from the leishmanin skin test are positive after 2-3 months of infection. No skin tests currently are approved for use in the United States.
    • Serologic tests are available in some centers and, as in the cutaneous form, PCR is becoming more common as a method of diagnosing the disease.
    • Because the organisms often are scarce, the diagnosis often is epidemiologic (travel to endemic area, clinical picture coupled with laboratory data).
  • Visceral leishmaniasis
    • Definitive diagnosis is made by observing the parasite (more specifically, amastigotes in tissue) on stained Giemsa smears or by observing the culture of bone marrow, splenic, hepatic, or lymph node aspirates. The most sensitive method is splenic puncture, although iatrogenic complications can be serious.
    • Cultures are grown on NNN medium (media available from the CDC), a biphasic medium, or liquid media with fetal calf serum (eg, Schneider Drosophila medium). Culture grows for 1-3 weeks.
    • Serologic testing is useful with the indirect fluorescent antibody test (IFAT), which is 80-100% sensitive in patients with visceral leishmaniasis who are not infected with HIV. IFAT may cross-react in patients who have leprosy, tuberculosis, malaria, schistosomiasis, Chagas disease, and African trypanosomiasis.
    • An enzyme-linked immunosorbent assay (ELISA) is now available and can be combined with IFAT and/or Western blot to increase sensitivity and specificity. If PCR is available, it is highly sensitive (between 92% and 99%) and specific (100%).
    • Obtain a complete blood count. Bone marrow infiltration may cause anemia, thrombocytopenia, and leukopenia with a relative monocytosis and lymphocytosis.
    • Perform liver function tests (LFTs).
    • Run a coagulation panel.
Next

Other Tests

  • Of note, very few of these diagnostic tests are available in developing countries, where most diagnoses are made clinically.
  • Monoclonal antibodies (MoAb) or hybridization of tissue touch blots with labeled kinetoplast DNA probes are used for identification of different strains of Leishmania.
  • An immunochromatographic strip test exists for rapid detection of antibodies to Leishmania antigen K39.
  • New research is being performed using PCR to detect clinically occult visceral leishmaniasis.
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Contributor Information and Disclosures
Author

Jennifer J Lee, MD  Attending Physician, Department of Dermatology, Beth Israel Deaconess Medical Center, Boston; Instructor, Department of Dermatology, Harvard Medical School

Jennifer J Lee, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Renee Y Hsia, MD, MSc  Clinical Instructor, Division of Emergency Medicine, University of California at San Francisco; Attending Physician, Department of Emergency Medicine, San Francisco General Hospital

Renee Y Hsia, MD, MSc is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, American College of Surgeons, American Heart Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John Halpern, DO, FACEP  Clinical Assistant Professor, Department of Family Medicine, Nova Southeastern University College of Osteopathic Medicine; Medical Director, Health Career Institute; Medical Director Emergency Department, Palms West Hospital

John Halpern, DO, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Edmond A Hooker II, MD, DrPH, FAAEM  Assistant Professor, Department of Emergency Medicine, University of Cincinnati College of Medicine

Edmond A Hooker II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, and Southern Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Jeter (Jay) Pritchard Taylor III, MD  Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina School of Medicine; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist

Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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Leishmaniasis. Image courtesy of the CDC Public Health Image Library.
Leishmaniasis. Photo courtesy of Robert Norris, MD, Stanford University Medical Center.
Leishmaniasis. Photo courtesy of Robert Norris, MD, Stanford University Medical Center.
Leishmaniasis. Image courtesy of the CDC Public Health Image Library.
Leishmaniasis. Ethiopian woman with 1-year history of asymptomatic pink-erythematous infiltrative plaque with overlying scale and central crust.
 
 
 
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