Do you have a sore on your skin that won't heal? Could it be Leishmaniasis? Let's talk about it!

Have you ever noticed that some people have sores on their skin that take a long time to heal, sometimes leaving ugly scars? Or a fever that lasts for days, weight loss, and a swollen belly? These can be symptoms of a disease that we sometimes don't pay much attention to, such as a small animal like a fly. One such disease is Leishmaniasis. Today, we will talk about this in detail, very simply.

What is Leishmaniasis?

Simply put, Leishmaniasis is a group of diseases caused by a parasite called Leishmania . This parasite is so small that it cannot be seen with the naked eye except under a microscope. Strictly speaking, it belongs to a group of organisms called protozoa, which are single-celled organisms.

This disease is transmitted to us when a type of sand fly bites us. These flies are very small, sometimes smaller than mosquitoes. This disease can cause a variety of conditions, from unsightly skin ulcers to life-threatening complications affecting internal organs.

There are two main ways we often see this:

1. Cutaneous leishmaniasis (`(Cutaneous leishmaniasis)`)

2. Visceral leishmaniasis ( which affects the internal organs )

Who is most likely to get this?

Leishmaniasis is most common in rural areas, especially in areas with poor sanitation . People with weakened immune systems , such as those infected with HIV or those with other immune deficiencies, are more likely to develop the disease if they become infected with the Leishmania parasite.

How common is Leishmaniasis? Does it exist in Sri Lanka?

Worldwide, some people infected with the Leishmania parasite do not develop symptoms. So it is difficult to say exactly how common it is. However, experts estimate that between 1.5 and 2 million people worldwide suffer from the disease with symptoms each year .

Yes, sadly, Leishmaniasis is also present in Sri Lanka. Especially the cutaneous form (`(Cutaneous leishmaniasis)`) has been reported in the dry zones of our country, for example in districts like Anuradhapura, Polonnaruwa, Hambantota, and Matara. Therefore, it is very important to be aware of this.

Where in the world is this most common?

The Leishmania parasite is found in more than 90 countries around the world. Different Leishmania species can be found in different parts of the world. Experts divide it into two types, "Old World leishmaniasis" and "New World leishmaniasis," depending on where it is found.

• Old World leishmaniasis (`(Old World leishmaniasis)`) in the Eastern Hemisphere, that is:
• Some parts of Asia
• In Africa, especially tropical and North African countries
• Southern Europe
• Middle East
• New World leishmaniasis (`(New World leishmaniasis)`) in the Western Hemisphere, that is:
• Central America
• South America
• Some areas of Mexico

Although it is uncommon in the United States, cases of cutaneous leishmaniasis have been reported from states such as Texas and Oklahoma.

What are the main types of Leishmaniasis?

Leishmaniasis can be divided into three main types: cutaneous, mucosal, and visceral.

Cutaneous Leishmaniasis (CL)

This is an infection that occurs on the skin where a sand fly has bitten . It starts as a small nodule and then turns into a large ulcer. These ulcers take a long time to heal, and sometimes they don't heal on their own. Symptoms can start within a few weeks to a few months after a sand fly bite.

Very rarely, some people may develop these lumps or lesions in multiple areas of the skin. This is called `(diffuse cutaneous leishmaniasis)`. These can recur even after treatment.

Mucosal/Mucocutaneous Leishmaniasis (ML)

This usually occurs as a complication of cutaneous leishmaniasis . It affects the mucous membranes inside the nose, mouth, or throat. The condition rarely resolves on its own and is often fatal if left untreated . It can also cause facial disfigurement.

Visceral Leishmaniasis (VL) / Kala-azar

This is the most severe form of the disease . It is caused by a specific type of Leishmania. It affects your internal organs, especially your spleen and liver . Symptoms can take anywhere from a few months to a year or more to appear after you have been bitten by an infected fly. This condition (VL) can become severe quickly and is almost always fatal if left untreated .

What are the symptoms of this disease?

The symptoms of leishmaniasis vary depending on the type you have. The types that affect the skin and mucous membranes cause large, slow-healing sores. The types that affect internal organs cause general symptoms like fever, weight loss, and abdominal swelling.

Symptoms of Cutaneous Leishmaniasis

A bump forms on the skin where a sandfly has bitten. It may have a scab/crust on top. Over time, it turns into a sore, with a hard edge around it and a sunken area in the middle (like a volcano) .

Symptoms of Mucosal Leishmaniasis

Sores on the mucous membranes inside the nose, mouth, or throat. These sores are usually preceded or accompanied by one or more skin sores.

Symptoms of Visceral Leishmaniasis

These symptoms include:

• Fever: This may start suddenly and may come and go for weeks.
• Feeling cold and sweating.
• Swollen lymph nodes.
• Abdominal swelling due to an enlarged spleen.
• Weight loss.
• Excessive tiredness, fatigue.
• Weakness.
• Darkening or discoloration of some areas of the skin.

What causes Leishmaniasis? How is it transmitted?

Leishmaniasis is caused by parasites called Leishmania. These parasites live in humans as well as in animals such as dogs, cats, opossums, rats, and foxes.

It is transmitted mainly through the bite of a type of fly called the phlebotomine sand fly . When this fly bites an infected person or animal, and then bites another person, it injects the Leishmania parasite into the other person's body.

Apart from this, other ways you can become infected with Leishmania, which is very rare, are:

• By sharing needles.
• Through a blood transfusion.
• From a pregnant mother to the child in the womb.

Important: You cannot get leishmaniasis directly from a dog or any other animal. However, there is evidence that dogs can transmit it to other dogs. Since dogs can also transmit it to humans through sand flies, it is important to prevent dogs from getting it.

How do you know if you have Leishmaniasis?

A doctor checks for the disease by taking tissue samples from your body and testing them for the Leishmania parasite. These samples can be taken from wounds, spleen, lymph nodes, or bone marrow. In countries where leishmaniasis is common, doctors often diagnose the disease by listening to the symptoms or examining the skin.

What tests are performed?

• Needle biopsy: A doctor uses a needle to take a sample of tissue from your spleen, lymph node, or bone marrow. A lab technician looks at it under a microscope to see if Leishmania is present. This is the best way to diagnose visceral leishmaniasis.
• Skin biopsy: A doctor takes a tissue sample from a sore on your skin, nose, or mouth. It is tested for Leishmania. This helps diagnose cutaneous or mucosal leishmaniasis.
• Blood tests (Serology) : Sometimes a doctor can check your blood for signs of Leishmania infection. However, blood tests are not usually very useful in detecting an existing infection. Because some people can have it without symptoms, a blood test can be positive even if you don't currently have the infection.

What are the treatments for this?

There are several types of anti-parasitic medications that can be used to treat Leishmaniasis. The medication your doctor prescribes will depend on the type of Leishmaniasis you have. These medications can come in different forms:

• Swallowing pills.
• Skin-soothing creams or lotions.
• Fluids given by a doctor through a saline tube (IV catheter) inserted into a vein.

If you have cutaneous leishmaniasis, your doctor may apply heat therapy (thermotherapy), cold therapy (cryotherapy), or laser therapy directly to the lesions. These can kill the parasite and help the lesions heal.

Medications for Leishmaniasis:

• Amphotericin
• Miltefosine
• Pentavalent antimonials, for example sodium stibogluconate
• Paromomycin

Other treatments are sometimes given for cutaneous leishmaniasis. These include:

• Thermotherapy : The doctor applies heat to the wound and the surrounding area.
• Cryotherapy : The doctor cools the wound and the surrounding area for about 10-30 seconds.
• Laser therapy : The doctor uses a handheld device to direct laser beams at the wound and surrounding area.

How to avoid Leishmaniasis?

The best way to avoid all types of Leishmaniasis is to avoid being bitten by sand flies , especially in areas where Leishmania is common. Here are some ways to avoid sand fly bites:

• Wear clothes that cover your body well: long pants, long-sleeved shirts, socks, etc.
• Use an EPA-approved insect repellant. The most effective repellents usually contain DEET.
• Spray insecticide to kill sand flies inside homes, such as bedrooms and living rooms.
• Sleep in a room with the windows closed or with screens on the windows.
• Sleep under a mosquito bed netting. Some nets are pre-treated with insect repellent for extra protection. Sand flies are much smaller than mosquitoes. So the holes in the netting should be very small to stop the flies from getting in.

What happens if you get Leishmaniasis? Can it be cured?

If you develop this disease, your prognosis depends on the type you have and the health of your immune system. The type that affects internal organs (VL) and the type that affects mucous membranes (ML) need to be treated quickly. Both are almost always fatal if left untreated.

Cutaneous leishmaniasis can resolve spontaneously or with treatment. However, it can take months to fully heal, and permanent scarring can occur.

You may need to continue taking the medication for weeks or months to make sure the infection is completely gone. Ask your doctor about treatment and recovery time.

Leishmaniasis is often curable if a doctor diagnoses the disease early and treats it with medication. With early treatment, the cure rate for visceral leishmaniasis is over 90%, and for mucosal leishmaniasis, it is over 75%. Some people can get sick again a few months after they have recovered and are free of the parasite (this is called a relapse).

Visceral and mucosal leishmaniasis is difficult to treat if left untreated. It is also difficult to treat in people with weakened immune systems.

What are the complications of this disease?

Complications of leishmaniasis can be severe or life-threatening, especially in the visceral and mucosal forms. They include:

• Bacterial infections: These are also called secondary infections. These can make wounds worse. Bacteria can travel deep into the body and cause serious illnesses.
• Scarring: Cutaneous and mucosal leishmaniasis can cause permanent damage and severe scarring of the skin, mouth, and nose.
• Relapse: Some people have symptoms that go away with treatment and then come back. Skin lesions that come back are called ``leishmaniasis recidivans.'' If this happens, additional treatment may be needed.
• Septal perforation or collapse: Mucosal leishmaniasis can cause a hole in the tissue between the two nasal passages (the septum). The structure of the nose can collapse. This can cause deformities, infections, and breathing difficulties.
• Pneumonia or gastrointestinal tract infections (GI (gastrointestinal) tract infections): Mucosal and visceral leishmaniasis can cause infections in other parts of the body.

Additional complications of visceral leishmaniasis:

• Post kala-azar dermal leishmaniasis (PKDL): PKDL is a condition that causes large, lumpy lesions on the face or other parts of the body. It can occur during or after visceral leishmaniasis. It can last a long time and can cause severe scarring.
• Severe bleeding: Excessive bleeding can be fatal.
• Hemophagocytic lymphohistiocytosis: This is a life-threatening, organ-damaging condition.
• Sepsis: Sepsis is the body's life-threatening response to a severe infection.

How should I take care of myself?

Ask your doctor how to care for yourself until you recover. If you have cutaneous leishmaniasis, your doctor will tell you how to clean and care for the sores until they heal. With all types of leishmaniasis, watch for symptoms that come back even after you think you've recovered.

When should I see a doctor?

See your doctor in these cases:

• If you live in an area where Leishmania is common or have traveled and have symptoms.
• If a wound on your skin takes a long time to heal.
• If your immune system is weak or you have any signs of infection, see a doctor.

If you don't have any symptoms after being bitten by a sand fly, you don't need to see a doctor. Not all sand flies spread disease. Sometimes our bodies can fight off a Leishmania infection without causing illness. Unless your immune system is weak or you are already sick, doctors usually won't treat you.

When should you go to an Emergency Treatment Unit (ETU) ?

If you have these severe symptoms, go to the nearest emergency room:

• If you have a high fever (over 103 Fahrenheit / 40 Celsius) that does not go down.
• Difficulty breathing.
• A very visible swelling of the abdomen.
• Yellowing of the skin or eyes (jaundice).
• Blue color of the skin, lips, or fingernails (cyanosis, a sign of low oxygen in the blood).

What questions should I ask the doctor?

It may be helpful to ask your doctor these questions:

• What treatment options do I have?
• How should I take care of my wounds?
• When will I get better/will my injuries heal?
• How serious is my illness?
• How should I take my medicine?
• When should I go to the emergency room?
• When should I see you again?

Remember as a summary

Leishmaniasis is a parasitic disease that can cause painful, life-threatening conditions. If you live in or are traveling to an area where Leishmania is common, take steps to protect yourself. If you have symptoms of Leishmaniasis, or if you have a sore that doesn't heal or gets worse, be sure to seek medical attention. Most people who get treatment before it gets worse can make a full recovery. Therefore, it is important to be aware of these symptoms and seek treatment promptly.

` leishmaniasis, kala-azar, sand fly, skin ulcer, parasite