Leishmaniasis refers to several different illnesses caused by infection with an organism called a protozoan.
Protozoa are considered to be the most simple organisms in the animal kingdom. They are all single-celled. The types of protozoa that cause leishmaniasis are carried by the blood-sucking sandfly. The sandfly is referred to as the disease vector, simply meaning that the infectious agent (the protozoan) is carried by the sandfly and passed on to other animals or humans in whom the protozoan will set up residence and cause disease. The animal or human in which the protozoan then resides is referred to as the host.
Once the protozoan is within the human host, the human's immune system is activated to try to combat the invader. Specialized immune cells called macrophages work to swallow up the protozoa. Usually, this technique kills a foreign invader, but these protozoa can survive and flourish within macrophages. The protozoa multiply within the macrophages, ultimately causing the macrophage to burst open. The protozoa are released, and take up residence within other neighboring cells.
At this point, the course of the disease caused by the protozoa is dependent on the specific type of protozoa, and on the type of reaction the protozoa elicits from the immune system. There are several types of protozoa that cause leishmaniasis, and they cause different patterns of disease progression.
At any one time, about 20 million people throughout the world are infected with leishmaniasis. Between one million and one and one-half million cases of cutaenous leishmaniasis are reported yearly worldwide. While leishmaniasis exists as a disease in 88 countries on five continents, some countries are hit harder than others. These include Bangladesh, India, Nepal, Sudan, Afghanistan, Brazil, Iran, Peru, Saudi Arabia, and Syria. Other areas that harbor the causative protozoa include China, many countries throughout Africa, Mexico, Central and South America, Turkey, and Greece. Although less frequent, cases have occurred in the United States, in Texas.
As Americans travel to these countries, they will come in contact the protozoa that cause forms of leishmaniasis. Also, physicians were advised in 2004 to suspect cutaneous leishmaniasis in military personnel who were deployed to areas where the infection is present. From August 2002 to February 2004, staff from the U.S. Department of Defense identified 522 confirmed cases of the disease in American military personnel.
In some areas of southern Europe, leishmaniasis is becoming an important disease that infects people with weakened immune systems. In particular, individuals with acquired immunodeficiency syndrome (AIDS ) are at great risk of this infection.
Causes and symptoms
There are a number of types of protozoa that can cause leishmaniasis. Each type exists in specific locations, and there are different patterns to the kind of disease each causes. The overall species name is Leishmania (commonly abbreviated L.). The specific types include: L. Donovani, L. Infantum, L. Chagasi, L. Mexicana, L. Amazonensis, L. Tropica, L. Major, L. Aethiopica, L. Brasiliensis, L. Guyaensis, L. Panamensis, L. Peruviana. Some of the names are reflective of the locale in which the specific protozoa is most commonly found, or in which it was first discovered.
Localized cutaneous leishmaniasis
This type of disease occurs most commonly in China, India, Asia Minor, Africa, the Mediterranean Basin, and Central America. It has occurred in an area ranging from northern Argentina all the way up to southern Texas. It is called different names in different locations, including chiclero ulcer, bush yaws, uta, oriental sore, Aleppo boil, and Baghdad sore.
This is perhaps the least drastic type of disease caused by any of the Leishmania. Several weeks or months after being bitten by an infected sandfly, the host may notice an itchy bump (lesion) on an arm, leg, or face. Lymph nodes in the area of this bump may be swollen. Within several months, the bump develops a crater (ulceration) in the center, with a raised, reddened ridge around it. There may be several of these lesions near each other, and they may spread into each other to form one large lesion. Although localized cutaneous leishmaniasis usually heals on its own, it may take as long as one year. A depressed, light-colored scar usually remains behind. Some lesions never heal, and may invade and destroy the tissue below. For example, lesions on the ears may slowly, but surely, invade and destroy the cartilage that supports the outer ear.
Diffuse cutaneous leishmaniasis
The lesions of diffuse cutaneous leishmaniasis are very similar to those of localized cutaneous leishmaniasis, except they are spread all over the body. The body's immune system apparently fails to battle the protozoa, which are free to spread throughout. The characteristic lesions resemble those of the dread biblical disease, leprosy.
This form of leishmaniasis occurs primarily in the tropics of South America. The disease begins with the same sores noted in localized cutaneous leishmaniasis. Sometimes these primary lesions heal, other times they spread and become larger. Some years after the first lesion is noted (and sometimes several years after that lesion has totally healed), new lesions appear in the mouth and nose, and occasionally in the area between the genitalia and the anus (the perineum). These new lesions are particularly destructive and painful. They erode underlying tissue and cartilage, frequently eating through the septum (the cartilage that separates the two nostrils). If the lesions spread to the roof of the mouth and the larynx (the part of the wind pipe which contains the vocal cords), they may prevent speech. Other symptoms include fever, weight loss, and anemia (low red blood cell count). There is always a large danger of bacteria infecting the already open sores.
This type of leishmaniasis occurs in India, China, the southern region of Russia, and throughout Africa, the Mediterranean, and South and Central America. It/is frequently called Kala-Azar or Dumdum fever.
In this disease, the protozoa use the bloodstream to travel to the liver, spleen, lymph nodes, and bone marrow. Fever may last for as long as eight weeks, disappear, and then reappear again. The lymph nodes, spleen, and liver are often quite enlarged. Weakness, fatigue, loss of appetite, diarrhea, and weight loss are common. Kala-azar translates to mean "black fever." The name kala-azar comes from a characteristic of this form of leishmaniasis. Individuals with light-colored skin take on a darker, grayish skin tone, particularly of their face and hands. A variety of lesions appear on the skin.
Diagnosis for each of these types of leishmaniasis involves taking a scraping from a lesion, preparing it in a laboratory, and examining it under a microscope to demonstrate the causative protozoan. Other methods that have been used include culturing a sample piece of tissue in a laboratory to allow the protozoa to multiply for easier microscopic identification; injecting a mouse or hamster with a solution made of scrapings from a patient's lesion to see if the animal develops a leishmaniasis-like disease; and demonstrating the presence in macrophages of the characteristic-appearing protozoan, called Leishman-Donovan bodies.
In some forms of leishmaniasis, a skin test (similar to that given for TB) may be used. In this test, a solution containing a small bit of the protozoan antigen (cell marker that causes the human immune system to react) is injected or scratched into a patient's skin. In a positive reaction, cells from the immune system will race to this spot, causing a characteristic skin lesion. Not all forms of leishmaniasis cause a positive skin test, however.
The treatment of choice for all forms of leishmaniasis is a type of drug containing the element antimony. These include sodium sitogluconate, and meglumin antimonate. When these types of drugs do not work, other medications with anti-protozoal activity are utilized, including amphotericin B, pentamidine, flagyl, and allopurinol. In 2004, it was reported that the world's first non-profit drug company was seeking approval in India for a drug to cure visceral leishmaniasis. An estimated 200,000 people die annually from the disease in that country. The company, called OneWorld Health, hoped to offer the drug called paromomycin for a day for a three-week treatment course.
The prognosis for leishmaniasis is quite variable, and depends on the specific strain of infecting protozoan, as well as the individual patient's immune system response to infection. Localized cutaneous leishmaniasis may require no treatment. Although it may take many months, these lesions usually heal themselves completely. Only rarely do these lesions fail to heal and become more destructive.
Disseminated cutaneous leishmaniasis may smolder on for years without treatment, ultimately causing death when the large, open lesions become infected with bacteria.
Mucocutaneous leishmaniasis is often relatively resistant to treatment. Untreated visceral leishmaniasis has a 90% death rate, but only a 10% death rate with treatment.
Prevention involves protecting against sandfly bites. Insect repellents used around homes, on clothing, on skin, and on bednets (to protect people while sleeping) are effective measures.
Reducing the population of sandflies is also an important preventive measure. In areas where leishmaniasis is very common, recommendations include clearing the land of trees and brush for at least 984 ft (300 m) around all villages, and regularly spraying the area with insecticides. Because rodents often carry the protozoan that causes leishmaniasis, careful rodent control should be practiced. Dogs, which also carry the protozoan, can be given a simple blood test.
MacReady, Norma. "Leishmaniasis Hits Military Hot Spots." Internal Medicine News June 15, 2004: 58.
"Seeking First-time Approval." Chemist & Druggist May 8, 2004: 12.
"Treatment of Cutaneous Leishmaniasis Among Travelers Reviewed." Vaccine Weekly April 28, 2004: 58.
Host— The organism (such as a monkey or human) in which another organism (such as a virus or bacteria) is living.
Larynx— The part of the airway lying between the pharynx and the trachea.
Leishman-Donovan body— A body of a (trypanosomatid) protozoa at a particular and characteristic stage in its life cycle; the infectious (trypanosomatid) protozoa can cause leishmaniasis, and is relatively easy to identify at that stage.
Lesion— A disruption of the normal structure and function of a tissue by some disease process.
Macrophage— A cell of the immune system that engulfs and digests foreign invaders such as bacteria and viruses in an attempt to stop them from causing disease within the body.
Protozoa— A group of organisms which are the smallest members of the animal kingdom, consisting of a single cell.
Ulceration— An area of pitting and irritation.
Vector— A carrier organism (such as a fly or mosquito) that to delivers a virus (or other agent of infection) to a host.
"Leishmaniasis." Gale Encyclopedia of Medicine, 3rd ed.. . Encyclopedia.com. (December 16, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/leishmaniasis
"Leishmaniasis." Gale Encyclopedia of Medicine, 3rd ed.. . Retrieved December 16, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/leishmaniasis
Leishmaniasis is caused by protozoan parasites of the genus Leishmania that are spread by the bite of female phlebotomine sand flies of the genus Phlebotomus in the Old World and Lutzomyia in the New World.
Approximately 350 million people in eighty-eight countries are thought to be at risk for leishmania infection. The true number of infected individuals is unknown, as it is not considered a reportable disease in many of the affected countries. The World Health Organization (WHO) estimates that twelve million people are infected and that there are between 1.5 and 2 million new cases each year.
Leishmania infection occurs in a variety of mammalian hosts, including the domestic dog, rodents, and sloths. When a sand fly, a night-biting insect, takes a blood meal from an infected mammal, it will ingest leishmania parasites, called amastigotes, along with the blood. Over seven days leishmania multiply in the flight muscles and develop into infective, flagellated promastigote forms. When the sand fly next takes a blood meal, these promastigotes are injected into a new mammalian host, where they transform back into the amastigote form and begin to divide. Leishmania species are obligate intracellular parasites that infect and replicate in mononuclear phagocytic cells such as macrophages. Infection can also occur via blood transfusion, shared intravenous needles, or, rarely, direct contact with skin lesions. The incubation period in humans is usually from three to eight months, but can be as short as two weeks or as long as several decades.
The spectrum of clinical manifestations caused by leishmania is divided into three broad categories: cutaneous, mucocutaneous, and visceral leishmaniasis. Cutaneous leishmaniasis is found worldwide and results in skin lesions ranging from a single, discrete, self-healing ulcer to diffuse progressive induration. The spectrum of disease is determined by the species of the parasite and the ability of the host to mount a cell-mediated response. A hyper-immune response causes destructive changes such as those seen in mucocutaneous disease, and a hypo-immune response results in visceral and diffuse cutaneous leishmaniasis. In Old World cutaneous leishmaniasis, the usual causative species are L. major, L. tropica, or L. aethiopica. In the Americas, cutaneous lesions are usually the result of infection with L. braziliensis, L. mexicana, L. amazonensis, or L. panamensis.
In mucocutaneous leishmaniasis (also called espundia), the infection causes destruction of mucous membranes of the nose, mouth, and throat. This form of leishmania is found almost exclusively in the Americas and is seen predominantly in a subset of patients infected with L. braziliensis. Diffuse cutaneous leishmaniasisis, caused by L. aethiopica, is characterized by induration of skin without ulceration.
Visceral leishmaniasis, or kala-azar, is the most severe form of infection with parasites disseminated throughout the reticuloendothelial system. Patients experience fevers, night sweats, and weight loss. The spleen and liver become enlarged, sometimes massively. Blood work reveals anemia, leucopenia, thrombocytopenia, and a marked increase in gamma-globulin levels. If untreated, visceral leishmaniasis is virtually always fatal.
It used to be thought that each species of leishmania resulted in a particular clinical syndrome. However, it is now being recognized that there is considerable overlap in the clinical presentation of each species. Most people bitten by leishmania -infected sand flies will never manifest any evidence of the infection. After recovery from leishmaniasis, a person is immune for life from reinfection by that strain.
Conditions that impair cell-mediated immunity can result in more severe, disseminated leishmanial infections. This has been seen in organ transplant recipients and, most importantly, in persons infected with HIV (human immunodeficiency virus), in whom visceral leishmaniasis has become a frequent opportunistic infection in endemic regions.
Diagnosis is made by microscopic identification of the parasite in tissue samples, by growing the organisms in culture, or by polymerase chain reaction (PCR) of tissue. PCR is a test that will identify even trace amounts of leishmanial DNA in tissue. Samples are taken from the edge or base of a skin ulcer in cutaneous disease. Bone marrow or splenic aspirates are the best tissue samples in cases of visceral disease. Testing for serum antibodies against leishmania parasites may be helpful.
Cutaneous lesions often heal spontaneously. Treatment is undertaken when the lesions are in cosmetically disfiguring areas, when the infection is widespread, and for certain leishmania spp. that are less likely to heal (e.g., L. brasiliensis ). Pentavalent antimony (sodium stibogluconate, Pentostam), given either systemically or intralesionally, is the drug of choice for cutaneous lesions. Mucocutaneous and visceral leishmaniasis always require intravenous treatment with a pentavalent antimonial. Other effective medications for some species include amphotericin B (HIV-infected individuals) and pentamidine (for L. panamensis ).
As there are many animal reservoirs of infection, and as elimination of sand flies is unlikely, control of leishmaniasis depends on avoiding exposure to sand flies. This involves a combination of insect repellent, fine-meshed bed nets, and protective clothing, and avoiding areas known to harbor sand flies.
(see also: Communicable Disease Control; Tropical Infectious Diseases )
Arias, J. R.; Monteiro, P. S.; and Zicker, F. (1996). "The Reemergence of Visceral Leishmaniasis in Brazil." Emerging Infectious Diseases 2(2):145–146.
Berman, J. D. (1997). "Human Leishmaniasis: Clinical, Diagnostic, and Chemotherapeutic Developments in the Last 10 Years." Clinical Infectious Diseases 24:684–703.
Desowitz, R. S. (1991). "Kala Azar: The Long Anguish of the Black Sickness." In The Malaria Capers. New York: W. W. Norton & Company.
Evans, T. G. (1993). "Leishmaniasis." Infectious Disease Clinics of North America 7(3):527–546.
Hernandez-Perez, J. et al. (1999). "Visceral Leishmaniasis (Kala-azar) in Solid Organ Transplantation: Report of Five Cases and Review." Clinical Infectious Diseases 29:918–921.
Herwaldt, B. (1999). "Leishmaniasis." Lancet 354:1191–1199.
World Health Organization (2000). "The Leishmaniases and Leishmania /HIV Co-Infections—Fact Sheet No.116." WHO Information Fact Sheets. Geneva: Author.
"Leishmaniasis." Encyclopedia of Public Health. . Encyclopedia.com. (December 16, 2017). http://www.encyclopedia.com/education/encyclopedias-almanacs-transcripts-and-maps/leishmaniasis
"Leishmaniasis." Encyclopedia of Public Health. . Retrieved December 16, 2017 from Encyclopedia.com: http://www.encyclopedia.com/education/encyclopedias-almanacs-transcripts-and-maps/leishmaniasis
leishmaniasis (lēsh´mənī´əsĬs), any of a group of tropical diseases caused by parasitic protozoans of the genus Leishmania. The parasites live in dogs, foxes, rodents, and humans; they are transmitted by the bites of sand flies. There they infect the very white blood cells that normally would defend the body from such invaders. There are two forms of leishmaniasis. The more serious, called visceral leishmaniasis, affects the internal organs, causing fever, anemia, splenomegaly, and discoloration of the skin. Untreated, it can be fatal. The term kala-azar may be used as a synonym for visceral leishmaniasis, or reserved for more advanced cases of the form. The second, or cutaneous form, leaves deep, disfiguring sores at the site of the bite. The cutaneous form may result in mucosal leishmaniasis, typically several years to decades later, if the parasites move from the skin to the mucous membranes of the pharynx. Research suggests that the visceral form results at least in part from a genetic susceptibility. Treatment is mainly with meglumine antimoniate, sodium stibogluconate, and other drugs that contain antimony. Leishmaniasis is rarely seen in the United States, but is prevalent in South Asia, the Middle East, much of Africa, and parts of Central and South America.
"leishmaniasis." The Columbia Encyclopedia, 6th ed.. . Encyclopedia.com. (December 16, 2017). http://www.encyclopedia.com/reference/encyclopedias-almanacs-transcripts-and-maps/leishmaniasis
"leishmaniasis." The Columbia Encyclopedia, 6th ed.. . Retrieved December 16, 2017 from Encyclopedia.com: http://www.encyclopedia.com/reference/encyclopedias-almanacs-transcripts-and-maps/leishmaniasis
Leishmaniasis (leesh-muh-NYE-uh-sis) is a parasitic infection spread by sand flies. It causes symptoms ranging from sores on the skin to damage to internal organs.
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The disease occurs when a person becomes infected with any of several types of Leishmania parasites*. They spread to people through the bite of female sand flies and can cause different forms of illness, all of which are called leishmaniasis. Cutaneous (kyoo-TAY-nee-us) leishmaniasis affects the skin; mucocutaneous (myoo-ko-kyoo-TAY-nee-us) leishmaniasis attacks the mucous membranes* in the mouth, nose, and throat; and visceral (VIH-suh-rul) leishmaniasis (also known as systemic leishmaniasis or kala azar) damages internal organs, such as the liver* and spleen*.
- (PAIR-uh-sites) are organisms such as protozoa (one-celled animals), worms, or insects that must live on or inside a human or other organism to survive. An animal or plant harboring a parasite is called its host. Parasites live at the expense of the host and may cause illness.
- *mucous membranes
- are the moist linings of the mouth, nose, eyes, and throat.
- is a large organ located beneath the ribs on the right side of the body. The liver performs numerous digestive and chemical functions essential for health.
- is an organ in the upper left part of the abdomen that stores and filters blood. As part of the immune system, the spleen also plays a role in fighting infection.
Cutaneous and mucocutaneous infections can lead to severe scarring and permanent disfigurement. In patients with a mucocutaneous infection, the disease can destroy soft tissue in the mouth and nose, drastically deforming the face. The visceral form of the disease is considered the most dangerous. It can grow worse over time and is usually fatal if not treated. Leishmaniasis damages the immune system so that it cannot fight off infections; these infections are generally the cause of death, not leishmaniasis itself. In some countries, visceral disease has been found with increasing frequency in people who also have human immunodeficiency virus* infection.
- *human immunodeficiency
- (HYOO-mun ih-myoo-no-dih-FIHshen-see) virus , or HIV, is the virus that causes AIDS (acquired immunodeficiency syndrome).
The infection is most common in tropical and subtropical regions, such as countries in South America, Africa, and Asia, and the number of areas where it occurs continues to grow. The U.S. Centers for Disease Control and Prevention (CDC) estimates that one and a half million people around the world contract cutaneous leishmaniasis each year and half a million people experience the more serious visceral form of the disease. Ninety percent of the visceral cases are found in just five countries: India, Nepal, Bangladesh, Sudan, and Brazil. Leishmaniasis is exceptionally rare in the United States, although a few cutaneous cases have been diagnosed in rural southern Texas.
People cannot get leishmaniasis directly from other people. Instead, the disease spreads through the bite of blood-sucking sand flies. A fly bites an infected animal or person and takes in the parasite with its meal of blood. The Leishmania parasites reproduce in the fly, which can spread them when it bites another person. Sand flies are quite small—about a third of the size of a mosquito—and fly silently, so people often do not even know the flies are nearby. Less often, the disease can be transmitted through contaminated blood in a transfusion*, by sharing or reusing needles for injecting drugs, or from a mother to her baby during pregnancy or birth.
- (trans-FYOO-zhun) is a procedure in which blood or certain parts of blood, such as specific cells, are given to a person who needs them because of illness or blood loss.
Cutaneous leishmaniasis is marked by sores that often look like volcanoes: they have a central pit and a raised rim. They can be painful or painless and may be covered by scabs. The sores tend to appear on the face, arms, and legs, and some people have as many as 200 of them. Patients with cutaneous leishmaniasis also may have swollen lymph nodes* near the sores. In mucocutaneous cases, the lesions appear in the mouth, nose, and throat and gradually destroy the soft tissues in those areas.
- (LIMF) nodes are small, bean-shaped masses of tissue that contain immune system cells that fight harmful microorganisms. Lymph nodes may swell during infections.
The visceral form of the disease can cause lack of appetite, serious weight loss, fever (which can last from 2 weeks to 2 months), and increasing weakness. It also can lead to an enlarged spleen and liver and sometimes swollen lymph nodes. Blood tests may show that the patient has low levels of white blood cells, red blood cells, or platelets*. As the disease progresses, the skin can become dark and dry—a symptom that gave the disease the name kala azar (meaning “black fever”). In children, visceral leishmaniasis often begins suddenly, with fever, diarrhea, and cough.
- (PLATE-lets) are tiny, disk-shaped particles within the blood that play an important role in clotting.
Cutaneous leishmaniasis affects the skin, causing sores that may look like volcanoes: they have a central pit and a raised rim. The disease can destroy tissue and lead to permanent scarring. AP/Wide World Photos
A key to making the diagnosis is learning whether the patient has traveled to a country where leishmaniasis occurs. During the physical examination, the doctor also checks the patient’s body for the types of sores seen with the infection. The doctor may take blood samples and tissue samples from any sores that are found. These samples will be cultured*, examined for signs of the parasite, or tested for antibodies* to the parasite. For suspected cases of visceral infection, biopsies* of the abnormal tissue may be done.
- (KUL-churd) means subjected to a test in which a sample of fluid or tissue from the body is placed in a dish containing material that supports the growth of certain organisms. Over time, ranging from hours to weeks, the organisms will grow and can be identified.
- (AN-tih-bah-deez) are protein molecules produced by the body’s immune system to help fight specific infections caused by microorganisms, such as bacteria and viruses.
- (BI-op-seez) are tests in which a small sample of skin or other body tissue is removed and examined for signs of disease.
Doctors treat the infection with prescription medications; many of these medicines contain antimony*. Cutaneous cases usually can be treated at home, but visceral disease may require hospitalization and supportive care, such as intravenous* fluids. Patients who have severe disfigurement from cutaneous, and especially mucocutaneous, leishmaniasis often need reconstructive surgery to regain a normal appearance. However, such extensive (and expensive) treatment is not available to vast numbers of people in developing countries who contract this disease.
- (AN-tih-mo-nee) is an element that has properties of both metals and nonmetals and can kill or inhibit the growth of certain bacteria.
- (in-tra-VEE-nus) means within or through a vein. For example, medications, fluid, or other substances can be given through a needle or soft tube inserted through the skin’s surface directly into a vein.
Although some cases of cutaneous leishmaniasis clear up on their own, most cases of mucocutaneous and visceral infection will not get better without treatment. Left untreated, visceral disease typically leads to death within 2 years. Cutaneous cases may take several months to heal, even with treatment, and may return after the treatment has been completed.
The cutaneous and mucocutaneous forms of leishmaniasis often cause widespread scarring. In mucocutaneous cases, destruction of tissue in the mouth and nose can lead to facial deformity. Visceral disease can damage the immune system to the point that it is unable to fight off other infections. Some patients may need to have the spleen removed if it is trapping and destroying too many of the person’s blood cells, and advanced cases of disease often result in death.
Avoiding sand fly bites is the best way to limit the spread of leishmaniasis. In areas where the flies live, people are advised to stay inside from dusk until dawn, when the insects are most active. Wearing long-sleeved shirts, long pants, and socks and tucking pants into socks can reduce the amount of bare skin that is vulnerable to fly bites. Using insect repellent, staying in screened-in or air-conditioned areas, sleeping under mosquito netting, and spraying living areas with an insecticide to kill flies also can help lessen the risk of being bitten.
West Nile Fever
U.S. Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA 30333. The CDC provides a fact sheet and other information on leishmaniasis at its website.
Telephone 800-311-3435 http://www.cdc.gov
World Health Organization (WHO), Avenue Appia 20, 1211 Geneva 27, Switzerland. WHO tracks disease outbreaks around the world and offers information about leishmaniasis at its website.
Telephone 011-41-22-791-2111 http://www.who.int
"Leishmaniasis." Complete Human Diseases and Conditions. . Encyclopedia.com. (December 16, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/leishmaniasis-0
"Leishmaniasis." Complete Human Diseases and Conditions. . Retrieved December 16, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/leishmaniasis-0
"leishmaniasis." A Dictionary of Nursing. . Encyclopedia.com. (December 16, 2017). http://www.encyclopedia.com/caregiving/dictionaries-thesauruses-pictures-and-press-releases/leishmaniasis
"leishmaniasis." A Dictionary of Nursing. . Retrieved December 16, 2017 from Encyclopedia.com: http://www.encyclopedia.com/caregiving/dictionaries-thesauruses-pictures-and-press-releases/leishmaniasis
leish·man·i·a·sis / ˌlēshməˈnīəsəs/ • n. a tropical and subtropical disease caused by leishmania and transmitted by the bite of sandflies. It affects either the skin or the internal organs.
"leishmaniasis." The Oxford Pocket Dictionary of Current English. . Encyclopedia.com. (December 16, 2017). http://www.encyclopedia.com/humanities/dictionaries-thesauruses-pictures-and-press-releases/leishmaniasis
"leishmaniasis." The Oxford Pocket Dictionary of Current English. . Retrieved December 16, 2017 from Encyclopedia.com: http://www.encyclopedia.com/humanities/dictionaries-thesauruses-pictures-and-press-releases/leishmaniasis