MEDICAL PARASITOLOGY MEDICAL PARASITOLOGY &&

ENTOMOLOGYENTOMOLOGY

LECTURER:LECTURER:

SR. NORAZSIDA RAMLISR. NORAZSIDA RAMLI

BLOOD & TISSUE BLOOD & TISSUE FLAGELLATES/FLAGELLATES/

HAEMOFLAGELLATESHAEMOFLAGELLATES

Morphologic formsMorphologic formsThere are 4 morphologic forms seen in There are 4 morphologic forms seen in hemoflagellates:hemoflagellates:

1)1) AmastigoteAmastigote2)2) PromastigotePromastigote3)3) EpimastigoteEpimastigote4)4) TrypomastigoteTrypomastigote-they can exist in two or more of the 4 -they can exist in two or more of the 4

morphologic forms morphologic forms depending on the depending on the species.species.

Kingdom: Kingdom: Protisata Protisata Phylum:Phylum: Sarcomastigophora Sarcomastigophora Class:Class: Zoomastigophora Zoomastigophora Order:Order: Kimetoplastida Kimetoplastida Family:Family: Trypanosomatidae Trypanosomatidae Genus:Genus: LeishmaniaLeishmaniaSpecies:Species: donovani , tropica, mexicana, donovani , tropica, mexicana, braziliensisbraziliensis

Leismania sp.Leismania sp.

Can cause: Can cause: 1)1) Cutaneous leishmaniasis: a localized infection Cutaneous leishmaniasis: a localized infection

of the capillaries of the skin.of the capillaries of the skin.2)2) Mucocutaneous leishmaniasis: cause lesions Mucocutaneous leishmaniasis: cause lesions

of the skin and mucous membranes, of the skin and mucous membranes, specifically of the oral and nasal mucosa.specifically of the oral and nasal mucosa.

3)3) Visceral/sistemic leismaniasis: more Visceral/sistemic leismaniasis: more generalized symptoms leading to enlargement generalized symptoms leading to enlargement of the internal organs, especially the liver, of the internal organs, especially the liver, lymph nodes and spleen.lymph nodes and spleen.

Indistinguishable in appearance.Indistinguishable in appearance.

Differentiated based on:Differentiated based on:- Geographic distribution.Geographic distribution.- Pathogenesis.Pathogenesis.- Kinetoplast DNA (kDNA) analysisKinetoplast DNA (kDNA) analysis- DNA hibridizationDNA hibridization- Serologic testing. Serologic testing.

Geographical distributionGeographical distribution

Leishmania sp.Leishmania sp.

Divided into 4 groups:Divided into 4 groups:1) 1) Leishmania tropica complexLeishmania tropica complex – Old World – Old World

Cutaneous Leismaniasis.Cutaneous Leismaniasis.2) 2) Leishmania mexicana complexLeishmania mexicana complex – New – New

World Cutaneous Leishmaniasis.World Cutaneous Leishmaniasis.3) 3) Leishmania braziliensis complexLeishmania braziliensis complex – –

Mucocutaneous Laishmaniasis.Mucocutaneous Laishmaniasis.4) 4) Leishmania donovani complexLeishmania donovani complex – Visceral – Visceral

leishmaniasis.leishmaniasis.

Stage of lifeStage of life

Only have 2 stages of life:Only have 2 stages of life:

1)1) AmastigoteAmastigote

2)2) PromastigotePromastigote

AmastigoteAmastigoteSize: 5 by 3Size: 5 by 3µmµmShape: oval to Shape: oval to roundroundNucleus: One, Nucleus: One, eccentric.eccentric.Kinetoplast: Present,Kinetoplast: Present,

Consisting of dot-like Consisting of dot-like blepharoplast, with blepharoplast, with small axoneme and small axoneme and prabasal body.prabasal body.Flagellum: absentFlagellum: absent

PromastigotePromastigoteSize: 9-15Size: 9-15µmµmShape: long and Shape: long and slender.slender.Nucleus: one, Nucleus: one, central.central.Kinetoplast: Anterior Kinetoplast: Anterior end of the organism, end of the organism, no undulating no undulating membrane.membrane.Flagellum: Single, Flagellum: Single, anterior free anterior free flagellum.flagellum.

Leishmania tropica complexLeishmania tropica complex – Old – Old World Cutaneous Leismaniasis.World Cutaneous Leismaniasis.

L. tropicaL. tropica - mediterranean region, middle East, - mediterranean region, middle East, Armenia, Caspian region, Afghanistan, India and Armenia, Caspian region, Afghanistan, India and Kenya (particularly in urban areas)Kenya (particularly in urban areas)

L. aethiopicaL. aethiopica – Highlands of Ethiopia, Kenya and – Highlands of Ethiopia, Kenya and Southern Yemen.Southern Yemen.

L. majorL. major – Desert regions of Turkmenistan, – Desert regions of Turkmenistan, Uzbekistan and Kazakhstan, Northern Africa and Uzbekistan and Kazakhstan, Northern Africa and the Sahara, Iran, Syria, Israel and Jordan.the Sahara, Iran, Syria, Israel and Jordan.

MorphologyMorphology

Cause a chronic disease: cutaneous Cause a chronic disease: cutaneous leishmanisis.leishmanisis.

Also known as Oriental sore, Delhi boil Also known as Oriental sore, Delhi boil and dry or urban cutaneous leishmaniasis.and dry or urban cutaneous leishmaniasis.

Characterized by: production of dry, Characterized by: production of dry, raised, ulcerated lesions at bite sites.raised, ulcerated lesions at bite sites.

Vectored by: tiny sandflies of the genera Vectored by: tiny sandflies of the genera PhlebotomusPhlebotomus..

L. tropicaL. tropica

VectorVector: Phlebotomus : Phlebotomus sandflysandfly

Sandfly vs mosquitoSandfly vs mosquito

mosquito

sandfly

Life cycleLife cycle

Only the female sandfly transmits the parasites.Only the female sandfly transmits the parasites.

Vector draws a blood meal from an infected host Vector draws a blood meal from an infected host amastigotes form transform into amastigotes form transform into promastigotes n multiply (within fly gut)promastigotes n multiply (within fly gut) promastigotes migrate to the pharynx promastigotes migrate to the pharynx fly fly feeds again, transmitted to a new host feeds again, transmitted to a new host engulfed by reticuloendothelial cells engulfed by reticuloendothelial cells amastigotes multiply repeatedly by binary amastigotes multiply repeatedly by binary fission. fission. cell ruptures cell ruptures amastigotes invade amastigotes invade new macrophages and perpetuate the cycle. new macrophages and perpetuate the cycle.

Life cycleLife cycle

Transmission & PathogenesisTransmission & PathogenesisIncubation period vary from several weeks to as Incubation period vary from several weeks to as three years.three years.First sign of cutaneous leishmaniasis= the First sign of cutaneous leishmaniasis= the development of a small red papule at the initial development of a small red papule at the initial site of the insect bite.site of the insect bite.A local granulomatous response leads to the A local granulomatous response leads to the formation of a crateriform lesion formation of a crateriform lesion 2cm or more. 2cm or more.L. tropicaL. tropica n n L. aethiopicaL. aethiopica produce dry lesions.produce dry lesions.L. majorL. major produce moist lesions with a serous produce moist lesions with a serous exudate.exudate.Lesions can heal spontaneously but may leave Lesions can heal spontaneously but may leave serious scars.serious scars.

Contact spread of infection also possible.Contact spread of infection also possible.

Patient may produce multiple sores by Patient may produce multiple sores by scrathing and autoinoculating normal skin.scrathing and autoinoculating normal skin.

Diffuse cutaneous leishmaniasis (DCL):Diffuse cutaneous leishmaniasis (DCL):

-occur in anergic patient (who is unable to -occur in anergic patient (who is unable to amount an adequate immune respon).amount an adequate immune respon).

-characterized by the presence of multiple -characterized by the presence of multiple nodular lesions, particularly on the face nodular lesions, particularly on the face and limbs.and limbs.

-loaded with parasites and do not heal -loaded with parasites and do not heal spontaneously.spontaneously.

DCLDCL

Laboratory DiagnosisLaboratory Diagnosis

Montenegro (leishmanin) skin testMontenegro (leishmanin) skin test-delayed hypersensitivity reaction provoked by a -delayed hypersensitivity reaction provoked by a

suspension of killed leishmanial promastigotes suspension of killed leishmanial promastigotes administered intradermally.administered intradermally.

-local inflammatory reaction appears at the site of -local inflammatory reaction appears at the site of injection within 48-72 hours.injection within 48-72 hours.Microscopy examinationMicroscopy examinationIsoenzyme studiesIsoenzyme studiesMolecular diagnostic technique- PCRMolecular diagnostic technique- PCRSerologic test – ex: indirect fluorescent antibody Serologic test – ex: indirect fluorescent antibody assay.assay.

Treatment Treatment

Sodium stibogluconate (antimony sodium Sodium stibogluconate (antimony sodium gluconate: Pentostom).gluconate: Pentostom).

Meglumine antimonateMeglumine antimonate

GlucantimeGlucantime

Ampotericin BAmpotericin B

KetoconazoleKetoconazole

PreventionPrevention

Use of bed netting Use of bed netting

Insect repellent and residental sprayingInsect repellent and residental spraying

Rodent control in reducing transmission.Rodent control in reducing transmission.

Individuals with active lesions Individuals with active lesions promptly promptly treated, wound covered treated, wound covered to prevent to prevent autoinfection and further insect autoinfection and further insect transmission to other individuals.transmission to other individuals.

Leishmania mexicana complexLeishmania mexicana complex – – New World Cutaneous New World Cutaneous

LeishmaniasisLeishmaniasis

L. mexicanaL. mexicana – Belize, Guatemala, and the – Belize, Guatemala, and the Yucatan peninsula.Yucatan peninsula.

L. pifanoiL. pifanoi – Amazon river basin and parts – Amazon river basin and parts of Brazil and Venezuela.of Brazil and Venezuela.

L. amazonensisL. amazonensis – Amazon basin of Brazil. – Amazon basin of Brazil.

L. venezuelensisL. venezuelensis – forests areas of – forests areas of Venezuela.Venezuela.

L. garnhamiL. garnhami – Venezuelan Andes. – Venezuelan Andes.

Morphology Morphology

Distribution extends from Southern Texas in the Distribution extends from Southern Texas in the United states, through Mexico, Central and South United states, through Mexico, Central and South America.America.

L. mexicanaL. mexicana causes chiclero ulcer or Bay sore. causes chiclero ulcer or Bay sore.

L. pifanoiL. pifanoi causes DCL. causes DCL.

L. amazonensisL. amazonensis causes cutaneous and DCL. causes cutaneous and DCL.

L. venezuelensisL. venezuelensis causes cutaneous leishmaniasis. causes cutaneous leishmaniasis.

L. garnhamiL. garnhami causes Venezuelan Andean causes Venezuelan Andean cutaneous leishmaniasis.cutaneous leishmaniasis.

Life cycle Life cycle

Transmitted by Transmitted by LutzomiyaLutzomiya sandfly sandfly

Reservoir host: rodents, opossums, Reservoir host: rodents, opossums, domestic dog, cat etc.domestic dog, cat etc.

Life cycle same with Life cycle same with L. mexicanaL. mexicana complex. complex.

Life cycleLife cycle

Vector: Vector: LutzomiyaLutzomiya sandfly sandfly

Transmission & PathogenesisTransmission & PathogenesisL. mexicanaL. mexicana - produces a lesion known as - produces a lesion known as chiclero ulcer or Bay sore – common chiclero ulcer or Bay sore – common among workers who collect chicle gum among workers who collect chicle gum from the Chicazapote trees in the rain from the Chicazapote trees in the rain forest in Nicaragua, Guatemala, Belize forest in Nicaragua, Guatemala, Belize and the Yucatan peninsula of Mexico. and the Yucatan peninsula of Mexico. Clinical manifestation: a single cutaneous Clinical manifestation: a single cutaneous papule, nodule or ulcer located on the ear papule, nodule or ulcer located on the ear or face. Lesion generally heal or face. Lesion generally heal spontaneously but may cause cartilage spontaneously but may cause cartilage destruction and gross disfigurement.destruction and gross disfigurement.

L. pifanoi and L. amazonensisL. pifanoi and L. amazonensis – produce a – produce a single but more likely to progress to the single but more likely to progress to the DCL – the majority patient infected, DCL – the majority patient infected, clustered in the Amazon river Basin of clustered in the Amazon river Basin of Brazil and Venezuela. Brazil and Venezuela. Clinical presentation of DCL may be Clinical presentation of DCL may be confused with Leptomatous Leprosy.confused with Leptomatous Leprosy.L. garnhami and L. venezuelensisL. garnhami and L. venezuelensis – – assosiated with cutaneous leishmaniasis assosiated with cutaneous leishmaniasis in rural parts of Venezuela – infection with in rural parts of Venezuela – infection with either organism present with a solitary either organism present with a solitary lesion that is usually self-limiting. lesion that is usually self-limiting.

Leptomatous LeprosyLeptomatous Leprosy

Picture: Mildly elevated indurating nodules are seen on the face and extremities (gross findings).

DiagnosisDiagnosis

Giemsa stained smears –amastigotes will Giemsa stained smears –amastigotes will be seen.be seen.

Cultivation – promastigotes forms can be Cultivation – promastigotes forms can be obtained.obtained.

Immunological testing methods. Immunological testing methods.

Treatment Treatment

In most cases, the infections are self-In most cases, the infections are self-limiting and require no treatment.limiting and require no treatment.

Treatment is paramount if:Treatment is paramount if:

-the lesion should endure or -the lesion should endure or

-threaten cartilaginous structures; ear,nose.-threaten cartilaginous structures; ear,nose.

Therapeutic agents: same as the Therapeutic agents: same as the treatment of Oriental sore.treatment of Oriental sore.

PreventionPrevention

Same as the prevention ways of Oriental Same as the prevention ways of Oriental sore.sore.

applied insect repellent to the skin and applied insect repellent to the skin and garments along with aerial spraying.garments along with aerial spraying.

Leishmania braziliensis complexLeishmania braziliensis complex – – Mucocutaneous LeishmaniasisMucocutaneous Leishmaniasis

L. braziliensisL. braziliensis – Mexico to Argentina – Mexico to Argentina

L. panamensisL. panamensis – Panama and Columbia – Panama and Columbia

L. peruvianaL. peruviana – Peruvian Andes. – Peruvian Andes.

L. guyanensisL. guyanensis – Guiana and parts of Brazil – Guiana and parts of Brazil and Venezuela.and Venezuela.

Morphology Morphology Cause infections throughout the Americas Cause infections throughout the Americas from Mexico to Argentina.from Mexico to Argentina.The distinguishing feature of these The distinguishing feature of these infectious is the development of ulcers on infectious is the development of ulcers on or about the oral and nasal mucosaor about the oral and nasal mucosaL. braziliensisL. braziliensis causes espundia. causes espundia.L. guyanensisL. guyanensis causes pain bois. causes pain bois.L. peruvianaL. peruviana causes uta. causes uta.All cause considerable morbidity and All cause considerable morbidity and mortility in the endemic areas.mortility in the endemic areas.

espundiaespundia

Life cycleLife cycle

Same with Same with L. mexicanaL. mexicana complex complex

Vector: Vector: LutzomyiaLutzomyia and and PsychodopygusPsychodopygus sandflies.sandflies.

PathogenesisPathogenesis

The primary lesion-same manner as the Oriental The primary lesion-same manner as the Oriental sore: macrophage ingest the parasites sore: macrophage ingest the parasites become heavy laden with replicating become heavy laden with replicating amastigotes amastigotes tissue damage. tissue damage.

Invade mucous membranes of the mouth and Invade mucous membranes of the mouth and nasopharynx.nasopharynx.

Spread by: direct extension of the primary lesion Spread by: direct extension of the primary lesion or metastasis via the bloodstream or lymphatics.or metastasis via the bloodstream or lymphatics.

Progression of disease may take years.Progression of disease may take years.

Resulting disease: may produce ulcers Resulting disease: may produce ulcers that erode soft tissues of the face and that erode soft tissues of the face and palate or form polyp-like appendages in palate or form polyp-like appendages in the nasal cavity.the nasal cavity.Patient commonly present with Patient commonly present with enlargement of the regional lymph nodes enlargement of the regional lymph nodes and secondary bacterial infections.and secondary bacterial infections.Untreated Untreated patients generally succumb patients generally succumb to these secondary infection or to to these secondary infection or to starvation if destruction of the oral cavity is starvation if destruction of the oral cavity is extensive.extensive.

DiagnosisDiagnosis

By demonstrating amastigotes of By demonstrating amastigotes of Leishmania in Giemsa stained smears or Leishmania in Giemsa stained smears or biopsy material from the edge of an active biopsy material from the edge of an active ulcer.ulcer.

Cultivation.Cultivation.

Serologic test.Serologic test.

Montenegro skin test.Montenegro skin test.

TreatmentTreatment

Sodium antimony (Pentostom).Sodium antimony (Pentostom).

Cycloguanil pamoate (Camolar).Cycloguanil pamoate (Camolar).

Amphotericin B (Fungizone).Amphotericin B (Fungizone).

Meglumine antimonateMeglumine antimonate

GlucantimeGlucantime

KetoconazoleKetoconazole

PreventionPrevention

Personal protective measures such Personal protective measures such as :protecting clothing, insect repellents as :protecting clothing, insect repellents and etc.and etc.

Vector controlVector control

Reservoir host controlReservoir host control

Public health educational programs.Public health educational programs.

Prompt treatment of infected individuals Prompt treatment of infected individuals to break the cycle of disease transmission.to break the cycle of disease transmission.

Leishmania donovani complexLeishmania donovani complex – – Visceral leishmaniasisVisceral leishmaniasis

L. donovaniL. donovani – India, Pakistan, Thailand, – India, Pakistan, Thailand, parts of Africa and the Peoples Republic of parts of Africa and the Peoples Republic of China.China.

L. infantumL. infantum – Mediterranean area, Europe, – Mediterranean area, Europe, Africa, the Near East, and parts of the Africa, the Near East, and parts of the former Soviet Union.former Soviet Union.

L. chagasiL. chagasi – Central and South America. – Central and South America.

MorphologyMorphologyVisceral leishmanisis also known as Kala Azar Visceral leishmanisis also known as Kala Azar or dum-dum fever.or dum-dum fever.The most severe of the Leishmaniasis.The most severe of the Leishmaniasis.Generally a disease of juveniles and young Generally a disease of juveniles and young adults.adults.Natural reservoir: rodents and dog.Natural reservoir: rodents and dog.In India, man appears to be the only mamalian In India, man appears to be the only mamalian reservoir.reservoir.L. donovaniL. donovani complex –parasitize the complex –parasitize the reticuloendothelial cells, viscerotropic, infected reticuloendothelial cells, viscerotropic, infected macrophages remaining fixed or disseminate macrophages remaining fixed or disseminate throughout the body.throughout the body.

In the Mediterranean are, Europe, Africa, In the Mediterranean are, Europe, Africa, Soviet union – Soviet union – PhlebotomusPhlebotomus sandfly sandfly remains the vector. Natural reservoir: remains the vector. Natural reservoir: domesticated dogs, canines and domesticated dogs, canines and porcupines.porcupines.In the New World (Central and South In the New World (Central and South America) – America) – LutzomiyaLutzomiya sandfly remains the sandfly remains the vector. Natural reservoir: Foxes, domestic vector. Natural reservoir: Foxes, domestic dogs and cats.dogs and cats.

Life cycleLife cycleSame with Same with L. mexicanaL. mexicana complex. complex.The infected mononuclear phagocytes do not The infected mononuclear phagocytes do not remain confined to the skin or mucous remain confined to the skin or mucous membranes.membranes.Parasitized macrophages are carried by the Parasitized macrophages are carried by the bloodstream to lymphoid tissue throughout the bloodstream to lymphoid tissue throughout the body especially to the spleen, liver and bone body especially to the spleen, liver and bone marrow.marrow.Amastigotes multiply in great numbers in this Amastigotes multiply in great numbers in this tissues.tissues.Vectors: Vectors: PhlebotomusPhlebotomus sandfly and sandfly and LutzomiyaLutzomiya sandfly .sandfly .

Transmission & pathogenesisTransmission & pathogenesisTransmitted by sandflies.Transmitted by sandflies.

Incubation period: 3 weeks to 2 years.Incubation period: 3 weeks to 2 years.

The infected macrophages migrate by The infected macrophages migrate by lymphatic and hematogenous lymphatic and hematogenous spread to spread to distant lymphoid tissues throughout the distant lymphoid tissues throughout the body.body.

Transmission via blood transfusion is also Transmission via blood transfusion is also possible. possible.

Early symptoms: prodome of headache, Early symptoms: prodome of headache, malaise, fever, possible weight loss and malaise, fever, possible weight loss and abdominal pain.abdominal pain.Fever may occur in periodic intervals mimicking Fever may occur in periodic intervals mimicking tertian or quartan malaria. tertian or quartan malaria. Another symptoms: diarrhea, consistent with Another symptoms: diarrhea, consistent with typhoid fever, enlargement of liver and spleen typhoid fever, enlargement of liver and spleen (hepatosplendomegaly) and lymph nodes (hepatosplendomegaly) and lymph nodes (lymphadenopathy), and increase in serum (lymphadenopathy), and increase in serum globulin levels.globulin levels.Microscopically, parasitized macrophages may Microscopically, parasitized macrophages may be found in the tissue of the spleen, liver, heart, be found in the tissue of the spleen, liver, heart, kidneys, lymph nodes, intestines and bone kidneys, lymph nodes, intestines and bone marrow.marrow.

Rapid proliferation of reticuloendothelial Rapid proliferation of reticuloendothelial cells within the involved organs lead to cells within the involved organs lead to organ hypertrophy.organ hypertrophy.

Parasitized macrophages may crowd out Parasitized macrophages may crowd out other hematopoietic cells leading to other hematopoietic cells leading to various degrees of anemia and various degrees of anemia and leukopenia.leukopenia.

The infiltration of the intestinal mucosa The infiltration of the intestinal mucosa may result in ulceration and yield may result in ulceration and yield malabsorption, and wasting.malabsorption, and wasting.

As the patient become more emaciated, As the patient become more emaciated, the abdominal distention from the the abdominal distention from the hepatosplenomegaly becomes more hepatosplenomegaly becomes more pronounced.pronounced.A characteristic hyperpigmentation of the A characteristic hyperpigmentation of the forehead and hands, known in India as forehead and hands, known in India as Kala Azar, may also be observed.Kala Azar, may also be observed.The prognosis for untreated cases is poor.The prognosis for untreated cases is poor.Mortality rate cab be as high as 95%.Mortality rate cab be as high as 95%.In chronic cases, death ususally occurs In chronic cases, death ususally occurs from medical complications or bacterial from medical complications or bacterial infections within 2 years of diagnosis.infections within 2 years of diagnosis.

With treatment, the prognosis is usually With treatment, the prognosis is usually much better.much better.

Recovering leads to a lasting immunity.Recovering leads to a lasting immunity.

In some patients, a condition called post- In some patients, a condition called post- kala azar dermal leishmaniasis, or dermal kala azar dermal leishmaniasis, or dermal leishmoid, may develop following the leishmoid, may develop following the treatment with antimony compounds.treatment with antimony compounds.

The clinical presentation of this condition The clinical presentation of this condition is marked by the appearance of either is marked by the appearance of either erythematous or hypopigmented lesions erythematous or hypopigmented lesions anywhere on the body.anywhere on the body.

A butterfly rash is a characteristic of A butterfly rash is a characteristic of systemic lupus erythemous. – may systemic lupus erythemous. – may develop on the malar portion of the face.develop on the malar portion of the face.

The dermal lesions, whether a papule or The dermal lesions, whether a papule or patch, may progress to nodules and patch, may progress to nodules and resemble lepromatous leprosy.resemble lepromatous leprosy.

These lesions do contain viable parasites These lesions do contain viable parasites and can serve as a reservoir of infection.and can serve as a reservoir of infection.

DiagnosisDiagnosis

Tissues BiopsyTissues BiopsyDirect examination of stained smears.Direct examination of stained smears.Cultivation.Cultivation.Serologic test.Serologic test.Direct agglutination test (DAT).Direct agglutination test (DAT).Complement fixation test (CF).Complement fixation test (CF).Indirect fluorescence technique.Indirect fluorescence technique.Molecular diagnostic technique.Molecular diagnostic technique.Montenegro skin test (not reactive in people with Montenegro skin test (not reactive in people with active disease).active disease).

TreatmentTreatment

Pantavalent antimony sodium gluconate Pantavalent antimony sodium gluconate (Pentostom).(Pentostom).

Pentamidine isothionate (Lomidine)Pentamidine isothionate (Lomidine)

Amphotericin BAmphotericin B

Allopurinol + PentostomAllopurinol + Pentostom

Gamma interferon + Pentostom.Gamma interferon + Pentostom.

Prevention Prevention

Same with the others leishmania sp.Same with the others leishmania sp.

Promastigotes Promastigotes (left) and (left) and amastigotes amastigotes (right) of (right) of Leishmania Leishmania parasitesparasites. . Parasites have Parasites have been fixed in been fixed in Giemsa Giemsa stained. stained.