Paediatric Visceral Leishmaniasis in Italy: a ‘One Health’ approach is needed
© Lorusso et al.; licensee BioMed Central Ltd. 2013
Received: 19 March 2013
Accepted: 18 April 2013
Published: 29 April 2013
Here we describe a case of paediatric visceral leishmaniasis recorded in an infant initially suspected for acute lymphoblastic leukaemia due to the clinical and haematological presentation. Eventually the patient was found positive for Leishmania infantum infection and successfully treated. This case emphasises how pivotal a ‘One Health’ approach is for diagnosing this zoonotic disease; highlighting the importance of including Visceral Leishmaniasis in the differential diagnosis of leukaemia-like syndromes in infants travelling to, and living in, the Mediterranean region.
Visceral leishmaniasis (VL) is an endemic zoonosis in the Mediterranean basin, where it is caused by the kinetoplastid protozoan Leishmania infantum, and transmitted by sand flies of the genus Phlebotomus. After peaking in the post-second world war and, the incidence of infantile VL in Italy dramatically decreased to a few cases per year . At present, however, the actual occurrence of the disease in the country seems to be underestimated, due to misdiagnosing and underreporting.
Here we point out the case of a 31-month-old Italian infant initially suspected for acute lymphoblastic leukaemia (ALL), due to his clinical and haematological presentation, and eventually found positive and treated for L. infantum infection.
The present case highlights the importance of including VL in the differential diagnosis of leukaemia-like syndromes (e.g., splenomegaly and haematopoietic alterations) in infants living in or travelling to endemic areas like the Mediterranean basin. In this case, collecting information on the summer stay of the child at a seaside locality, apparently one of the commonest habits of middle class families in this part of Italy, eventually turned out to be pivotal anamnestic data, leading physicians to the correct interpretation of clinical and laboratory findings. In Italy, as well as in other southern European countries, the majority of patients diagnosed and treated for VL are indeed children aging under or equal to 3 years [4–6], due to the immaturity of their immune system . Noteworthy, the name ‘infantum’ was initially attributed to this Leishmania species for causing a visceral syndrome predominantly in infants in the Mediterranean region.
As the number of contacts with the phlebotomine vector has been suggested as being related to the likelihood for the human host to develop clinical illness , it was suspected that the patient was infected during his stay at the seaside, when he was more likely exposed to insect bites due to the frequent outdoor activities undertaken by his family. This assumption is further supported by the high abundance of sand flies and stray dogs in the area, with high prevalence (~50%) of infected, and often asymptomatic, animals . Furthermore, the abundance of other suitable reservoir host species, such as red foxes (Vulpes vulpes), enhances the risk of transmission of VL to humans in the surroundings . Importantly, in a recent study, Phlebotomus perniciosus and Phlebotomus neglectus, both competent vectors of L. infantum, were found in the same region, with the highest abundance recorded in July and August . This explains the common onset of the disease during the summer, as reported in other studies carried out in the Mediterranean region [4–6].
In this case, the conclusive diagnosis of VL was achieved by IFAT, already proven to be highly sensitive (i.e., 87–100%) and suitable for diagnosing VL in paediatric patients in presence of a strong clinical suspicion . The false negative result achieved by cytology of bone marrow can be attributed to the lower sensitivity (i.e., 52–80%) of such a diagnostic approach especially at the early stage of infection . The immunochromatographic rK39 test resulted negative, thus with low sensitivity, as previously reported in a field study in Sudan .
This case illustrates how a ‘One Health’ approach, based on the increased level of communication between physicians and veterinarians, is crucial for the management of VL in endemic areas . In this scenario, veterinarians and public health authorities play an essential role in reducing the risk of infections in humans . Where the elimination of the infection in the canine reservoir cannot be achieved, prompt diagnosis and treatment of human patients are indeed essential in order to reduce the public health impact of VL.
Authors are grateful to Dr Maria Stefania Latrofa (Università degli Studi di Bari, Italy), for carrying out the real-time PCR, Dr Ciro Lorusso, for his comments on laboratory results and the diagnostic course of the patient, and Fabio Di Chio, for the assistance with map design.
- Gramiccia M, Gradoni L: The current status of zoonotic leishmaniases and approaches to disease control. Int J Parasitol. 2005, 35: 1169-1180. 10.1016/j.ijpara.2005.07.001.View ArticlePubMedGoogle Scholar
- Cascio A, Gradoni L, Scarlata F, Gramiccia M, Giordano S, Russo R, Scalone A, Camma C, Titone L: Epidemiologic surveillance of visceral leishmaniasis in Sicily, Italy. Am J Trop Med Hyg. 1997, 57: 75-78.PubMedGoogle Scholar
- Otranto D, Capelli G, Genchi C: Changing distribution patterns of canine vector borne diseases in Italy: leishmaniosis vs. dirofilariosis. Parasit Vectors. 2009, 26 (2 Suppl 1): S2-View ArticleGoogle Scholar
- di Martino L, Gramiccia M, Occorsio P, Di Muccio T, Scalone A, Gradoni L: Infantile visceral leishmaniasis in the Campania region, Italy: experience from a Paediatric Referral Centre. Parassitologia. 2004, 46: 221-223.PubMedGoogle Scholar
- Maltezou HC, Siafas C, Mavrikou M, Spyridis P, Stavrinadis C, Karpathios T, Kafetzis DA: Visceral leishmaniasis during childhood in southern Greece. Clin Infect Dis. 2000, 31: 1139-1143. 10.1086/317455.View ArticlePubMedGoogle Scholar
- Petrela R, Kuneshka L, Foto E, Zavalani F, Gradoni L: Pediatric visceral leishmaniasis in Albania: a retrospective analysis of 1,210 consecutive hospitalized patients (1995–2009). PLoS Negl Trop Dis. 2010, 4: e814-10.1371/journal.pntd.0000814.PubMed CentralView ArticlePubMedGoogle Scholar
- Pearson RD, de Queiroz S: A Clinical spectrum of leishmaniasis. Clin Infect Dis. 1996, 22: 1-13. 10.1093/clinids/22.1.1.View ArticlePubMedGoogle Scholar
- Dipineto L, Manna L, Baiano A, Gala M, Fioretti A, Gravino AE, Menna LF: Presence of Leishmania infantum in red foxes (Vulpes vulpes) in southern Italy. J Wildl Dis. 2007, 43: 518-520.View ArticlePubMedGoogle Scholar
- Maroli M, Feliciangeli MD, Bichaud L, Charrel RN, Gradoni L: Phlebotomine sandflies and the spreading of leishmaniases and other diseases of public health concern. Med Vet Entomol.http://dx.doi.org/10.1111/j.1365-2915.2012.01034.x,
- Tarallo VD, Dantas-Torres F, Lia RP, Otranto D: Phlebotomine sand fly population dynamics in a leishmaniasis endemic peri-urban area in southern Italy. Acta Trop. 2010, 116: 227-234. 10.1016/j.actatropica.2010.08.013.View ArticlePubMedGoogle Scholar
- Boelaert M, Bhattacharya S, Chappuis F, El Safi SH, Hailu A, Mondal D, Rijal S, Sundar S, Wasunna M, Peeling RW: Evaluation of rapid diagnostic tests: visceral leishmaniasis. Nature. 2007, S30-S39.http://dx.doi.org/10.1038/nrmicro1766,Google Scholar
- Dantas-Torres F, Solano-Gallego L, Baneth G, Ribeiro VM, de Paiva-Cavalcanti M, Otranto D: Canine leishmaniosis in the old and new worlds: unveiled similarities and differences. Trends Parasitol. 2012, 28: 531-538. 10.1016/j.pt.2012.08.007.View ArticlePubMedGoogle Scholar
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