Visceral leishmaniasis generally conforms to the following cardinal signs of prolonged fever, anemia, leukopenia, splenomegaly and hypergammaglobulinemia. Cutaneous leishmaniasis may or may not present as a nodule at the site of the sandfly bite.

Generally, these presenting signs and symptoms governs the majority of leishmaniasis cases:

• Systemic signs of fever, weight loss, fatigue and dizziness are common in leishmaniasis. Fever is an immune response to the invading protozoan while dizziness and fatigue is anemia related. Weight loss is due to muscle wasting.
• Integumentary system: Skin may appear hyperpigmented at the forehead, abdomen, hands and feet. Jaundice may ensue with hepatic involvement.
• Head and neck: Signs of gum bleeding and epistaxis may be observable in some cases. Disfiguring lesions of the lips and nose may be a late sign of cutaneous leishmaniasis
• Abdominal enlargement due to splenomegaly and in some cases hepatomegaly.
• Extremities: Generalized lymphadenopathy may be observed in visceral leishmaniasis.

• Hemophilia A

  The personal history comprised HIV infection, hemophilia and surgery for a duodenal ulcer. The histological study of a biopsy of the oral lesion indicated leishmaniasis ( Fig. 3 ). [scielo.isciii.es]

• Splenomegaly

  Both patients were cured in two months; defervescence, reduction of splenomegaly, and healing of cutaneous lesions were all observed. [ncbi.nlm.nih.gov]

  Visceral leishmaniasis generally conforms to the following cardinal signs of prolonged fever, anemia, leukopenia, splenomegaly and hypergammaglobulinemia. Cutaneous leishmaniasis may or may not present as a nodule at the site of the sandfly bite. [symptoma.com]

  Visceral manifestations include pronounced splenomegaly (hard, non-tender) and to a lesser extent hepatomegaly. [wynman.com]

  Visceral leishmaniasis causes splenomegaly that is not always distinct from other forms of splenomegaly. Reported cases suggest that multiple nodular lesions in the spleen may occur 4-6. Promoted articles (advertising) [radiopaedia.org]

  Fever, weakness, abdominal pain, mucosal bleeding, and splenomegaly are the most common findings in VL. Hepatomegaly is seen in more than half of the cases. [intjinfection.com]

• Fever

  The term "kala-azar" comes from India where it is the Hindi for black fever. The disease is also known as Indian leishmaniasis, visceral leishmaniasis, leishmania infection, dumdum fever, black sickness, and black fever. [medicinenet.com]

  Other symptoms of systematic visceral leishmaniasis can include a fever that continues for weeks and even be in cycles, night sweats, stomach pains, thinning hair, and graying of the skin. [microbewiki.kenyon.edu]

  Vomiting Adults usually have a fever for 2 weeks to 2 months, along with symptoms such as fatigue, weakness, and appetite loss. [nlm.nih.gov]

  VL causes fever, weight loss, spleen and liver enlargement, and, if not treated, death. [dndi.org]

  Independent (1998) This parasite causes leishmaniasis, a disease that brings severe fever, weight loss, joint pain and swelling of the spleen and liver. New Scientist (1999) Log in to comment on this word. [web.archive.org]

• Malnutrition

  Malnutrition affects the immune response against infections and, among the several malnutrition forms, the protein deficiency in the diet is one of the most harmful forms. [portal.fiocruz.br]

  It affects the poorest of the poor and is associated with malnutrition, displacement, poor housing, illiteracy, gender discrimination, weakness of the immune system and lack of resources. [web.archive.org]

• Military Personnel

  Leishmaniasis has been reported in military personnel returning from the Persian Gulf. [nlm.nih.gov]

  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. [encyclopedia.com]

  personnel, construction workers and missionaries. [canada.ca]

• Falling

  The risk of an average American falling ill with it is very low. [medicaldaily.com]

  It is usually suggested only for people who have severe, uncontrollable seizures that cause them to fall and get hurt. [webmd.com]

  These syndromes fall into three broad categories: visceral leishmaniasis (VL), cutaneous leishmaniasis (CL), and mucosal leishmaniasis (ML). [accessmedicine.mhmedical.com]

  During these, the child will suddenly fall to the ground, which may at first be mistaken as tripping up or poor balance. In an atonic seizure the child will fall as if a puppet’s strings have been cut. [epilepsy.org.uk]

  Seizures are often frequent (multiple every day) and atonic seizures can result in falls and injuries (often children need to wear a helmet for safety). [epilepsyqueensland.com.au]

• Rigor

  Additionally, both treatments have the potential to cause side effects such as rigors, fever, and liver, kidney or heart disease, which has been estimated at up to 85% for treatment with SSG and 98% for amphotericin B in India. [microbiologysociety.org]

  “We’ll continue to support rigorous scientific research on the potential medical uses of marijuana-derived products and work with product developers who are interested in bringing patients safe and effective, high quality products,” furthered Dr Scott [mdmag.com]

  However, no rigorous studies prove this commonly accepted rate. Visceral leishmaniasis Visceral leishmaniasis is a serious, progressive, and potentially lethal systemic disease. [emedicine.medscape.com]

• Pneumonia

  Advanced untreated visceral leishmaniasis can be fatal, particularly if other pre-existing conditions such as tuberculosis, pneumonia, and dysentry are present. Prevention Avoid outdoor activities from dusk to dawn. [iamat.org]

  Five pneumonia cases associated with visceral leishmaniasis in Turkey. Int Pediatr. 2003;18(3):185-7. 10. Kotsifas K, Metaxas E, Koutsouvelis I, Skoutelis A, Kara P, Tatsis G. [intjinfection.com]

  […] en Leishmaniasis doesn't cause pneumonia, and filariasis- tr Sadece kontrol için kullanılan kristalleri yok etmemiz gerek en Last year, hundreds of volunteer biology and chemistry researchers around the world worked together to sequence the genome of [tr.glosbe.com]

  Part Arthritis Joints Asthma Bronchial Muscles Cataract Eyes Diabetes Pancreas Diphtheria Throat Eczema Skin Glaucoma Eyes Goitre Thyroid Gland Jaundice Liver Leukemia Blood Malaria Spleen Meningitis Brain and Spinal Cord Otitis Ears Paralysis Nerves Pneumonia [ashutoshshuklaofficial123.blogspot.com]

  The clinical manifestations most often related to death were bleeding, edema (anasarca and ascites), and pneumonia. In the third and fourth weeks, 17 deaths were registered, with a predominance of pneumonia as a probable cause of death. [intechopen.com]

• Loss of Appetite

  Kala-azar can cause no or few symptoms but typically it is associated with fever, loss of appetite ( anorexia ), fatigue, enlargement of the liver, spleen and nodes and suppression of the bone marrow. [medicinenet.com]

  Visceral Leishmaniasis (also known as Kala-azar) The infection spreads to the liver, spleen and bone marrow causing fever, loss of appetite, weight loss and abdominal pain. This form is often fatal if untreated. [fitfortravel.nhs.uk]

  Visceral — affects organs of the abdominal cavity Severe weight loss Loss of appetite (anorexia) Diarrhea Tarry feces (less common) Vomiting Nose bleed Exercise intolerance Cutaneous — affects the skin Hyperkeratosis — most prominent finding; excessive [petmd.com]

  During its acute stage, the infection causes fever, body aches, rash, headaches, loss of appetite, vomiting and diarrhea. If left untreated, the disease may pose life-threatening complications. [techtimes.com]

• Abdominal Pain

  Visceral Leishmaniasis (also known as Kala-azar) The infection spreads to the liver, spleen and bone marrow causing fever, loss of appetite, weight loss and abdominal pain. This form is often fatal if untreated. [fitfortravel.nhs.uk]

  You have severe abdominal pain. Your skin or the whites of your eyes turn yellow. When should I contact my healthcare provider? Your skin has signs of infection, such as pus or swelling. Your symptoms do not get better with treatment. [drugs.com]

  Fever, weakness, abdominal pain, mucosal bleeding, and splenomegaly are the most common findings in VL. Hepatomegaly is seen in more than half of the cases. [intjinfection.com]

  Risks with CBD include: suicidal thoughts, suicide attempts, feelings of agitation, new or worsening depression, aggression and panic attacks in addition to liver injury, which can cause nausea, vomiting, abdominal pain, fatigue, anorexia, jaundice and [mdmag.com]

  Side effects were arthralgias, myalgias, itch, rash, nausea, anorexia, abdominal pain, cough and headache. [dx.doi.org]

• Hepatomegaly

  Hepatomegaly is less frequent than splenomagaly. Jaundice, edema, and ascitis are reported less frequently. [intechopen.com]

  Disfiguring lesions of the lips and nose may be a late sign of cutaneous leishmaniasis Abdominal enlargement due to splenomegaly and in some cases hepatomegaly. Extremities: Generalized lymphadenopathy may be observed in visceral leishmaniasis. [symptoma.com]

  Visceral manifestations include pronounced splenomegaly (hard, non-tender) and to a lesser extent hepatomegaly. [wynman.com]

  […] whole body Follows a chronic relapsing or progressive course Often difficult to treat Visceral leishmaniasis (VL) VL affects internal organs including the spleen, liver and lymph nodes Signs and symptoms include fever, weight loss, lymphadenopathy, hepatomegaly [dermnetnz.org]

• Jaundice

  Jaundice, edema, and ascitis are reported less frequently. [intechopen.com]

  Jaundice may ensue with hepatic involvement. Head and neck: Signs of gum bleeding and epistaxis may be observable in some cases. [symptoma.com]

  Parts of the Body Affected by Diseases Disease Affected Body Part Arthritis Joints Asthma Bronchial Muscles Cataract Eyes Diabetes Pancreas Diphtheria Throat Eczema Skin Glaucoma Eyes Goitre Thyroid Gland Jaundice Liver Leukemia Blood Malaria Spleen Meningitis [ashutoshshuklaofficial123.blogspot.com]

  Risks with CBD include: suicidal thoughts, suicide attempts, feelings of agitation, new or worsening depression, aggression and panic attacks in addition to liver injury, which can cause nausea, vomiting, abdominal pain, fatigue, anorexia, jaundice and [mdmag.com]

• Skin Ulcer

  Cutaneous leishmaniasis Cutaneous ulcers will often heal without treatment. However, treatment can speed healing, reduce scarring, and decrease risk of further disease. Any skin ulcers that cause disfigurement may require plastic surgery. [healthline.com]

  Mucosal leishmaniasis may develop after the original skin ulcers of some forms of cutaneous leishmaniasis have been treated or have healed. Symptoms include nasal obstruction, discharge, nosebleed, and ulcers of the nose, mouth, or throat. [tripprep.com]

  Known locally as uta L. guyanensis The Guyana, Brazil Single skin ulcers, but lymphatic spread may result in widespread ulceration. Known locally as pian bois. [web.stanford.edu]

  The cutaneous symptoms are similar to those in humans (see below) and include: Skin ulcers mainly on the face Hairlessness Dandruff (squamosis) Seborrhoea Excessive long claws The viscerous form starts with the silent invasion by the Leishmania of the [lrd.spc.int]

• Night Sweats

  Other symptoms of systemic visceral leishmaniasis may include: Abdominal discomfort Fever that lasts for weeks; may come and go in cycles Night sweats Scaly, gray, dark, ashen skin Thinning hair Weight loss Your health care provider will examine you and [nlm.nih.gov]

  Other symptoms of systemic visceral leishmaniasis may include: Abdominal discomfort Fever that lasts for weeks; may come and go in cycles Night sweats Scaly, gray, dark, ashen skin Thinning hair Weight loss Exams and Tests Your health care provider will [ufhealth.org]

  Other symptoms of systematic visceral leishmaniasis can include a fever that continues for weeks and even be in cycles, night sweats, stomach pains, thinning hair, and graying of the skin. [microbewiki.kenyon.edu]

  Adults more often have bouts of fever, night sweats, tiredness and loss of appetite. There may also be abdominal discomfort, grey discoloration of the skin and weight loss. [news-medical.net]

• Pruritus

  Lack of pruritus, scaly appearance and erythema were highly significant lesion characteristics associated with Leishmania positive smears which can be used for the clinical diagnosis of CL. [ncbi.nlm.nih.gov]

  One month after treatment, the patient developed daily vomiting, asthenia, anorexia, febrile sensation and pruritus. [scielo.isciii.es]

  These lesions are usually painless and without evident systemic symptoms or pruritus. [intechopen.com]

  An erythematous asymptomatic papule appears at the site of the bite, although pruritus may be present. The size ranges from 1 to 10 mm in diameter. [f1000research.com]

• Eruptions

  With the current political unrest in the Middle East, CL outbreaks are erupting where conflict has disrupted health care systems (including vector control programmes) and forced people to flee into disease endemic areas. [microbiologysociety.org]

  Treatment is similar to other forms but disease can lie dormant erupting many years later in mucocutaneous sites. [wynman.com]

  This can diagnose the infection before it actively erupts when the organs are still unaffected. In this case, the symptoms can be alleviated extremely well by medication, which can prevent the pathogens from spreading further. [zooplus.ie]

  […] disease.[3] It is classified as a neglected tropical disease.[12] The disease may occur in a number of other animals, including dogs and rodents.[2] Signs and symptoms[edit] Cutaneous leishmaniasis ulcer The symptoms of leishmaniasis are skin sores which erupt [en.wikipedia.org]

  In our experience with consultation material of unrecognized cases of leishmaniasis, the original pathologic differential diagnosis often included acneiform eruptions, pseudolymphoma, juvenile xanthogranuloma, and squamous cell carcinoma, among others [jamanetwork.com]

The presence of the cardinal signs mentioned above and the history of travel to endemic areas for leishmaniasis clinches the diagnosis of the disease. The following additional tests may be used to determine the presence of leishmania in a host:

• Bone marrow and splenic aspirate may be examined in the microscope to demonstrate the actual protozoan. This is the most sensitive test available for leishmaniasis. Polymerase Chain Reaction (PCR) may be implored to aid the diagnosis.
• Blood smear and nasopharyngeal swabs may demonstrate the presence of the amastigotes through Giemsa staining techniques.
• Direct Agglutination Test or ELISA test may detect the parasite very early in the course of the disease.
• Leishmanin skin test conveys a positive result after an active disease.
• Culture of Leishmania may require a specialized media.

• Enlargement of the Liver

  Common signs and symptoms include: weight loss weakness fever that lasts for weeks or months enlarged spleen enlarged liver decreased production of blood cells bleeding other infections swollen lymph nodes It’s important to tell your doctor if you lived [healthline.com]

  The visceral type affects internal organs such as the spleen, liver, and bone marrow. People with this form usually have fever, weight loss, and an enlarged spleen and liver. Leishmaniasis is found in parts of about 88 countries. [medlineplus.gov]

  Kala-azar can cause no or few symptoms but typically it is associated with fever, loss of appetite ( anorexia ), fatigue, enlargement of the liver, spleen and nodes and suppression of the bone marrow. [medicinenet.com]

  VL causes fever, weight loss, spleen and liver enlargement, and, if not treated, death. [dndi.org]

• Hypoalbuminemia

  Laboratory Findings: Leukopenia, hypergammaglobulinemia, hypoalbuminemia; thromboctopenia with hemorrhagic fever. [wynman.com]

  Serum biochemistry revealed hyperproteinemia 100.0 g/L [54.0 – 82.0 g/L], hyperglobulinemia 83.0 g/L [23.0 – 52.0 g/L] and hypoalbuminemia 18.0 g/L [25.0 – 44.0 g/L]. [parasitesandvectors.biomedcentral.com]

  The most consistent serum biochemistry findings in dogs with clinical canine leishmaniosis are serum hyperproteinemia with hyperglobulinemia and hypoalbuminemia, frequently expressed by a decreased albumin:globulin ratio. [merckvetmanual.com]

  Protein imbalance is represented by the increase of total serum proteins (hyperproteinemia), hyperglobulinemia, and hypoalbuminemia, which also determines the inversion in the albumin/globulin ratio. [hindawi.com]

• Neutropenia

  Hepatosplenomegaly Ascites and edema Pancytopenia Possible darkened or gray skin color (especially on the palms and soles) Immunosuppression may lead to secondary bacterial infections in advanced disease Diagnostics Laboratory tests Hemolytic anemia Neutropenia [amboss.com]

  […] possible adverse effects of these drugs are: myalgia, joint pain, anorexia, nausea, vomiting, headache, electrocardiographic changes (T-wave inversion, prolongation of the QT interval), hypertransaminemia, chemical pancreatitis, thrombocytopenia and neutropenia [scielo.isciii.es]

  Patients may have bleeding or neutropenia leading to infectious conditions such as pneumonia or diarrhea. Transfusions may be necessary for severe bleeding or anemia. Antibiotics are indicated to treat intercurrent infectious conditions. [emedicine.medscape.com]

  A hypomorphic mutation in the Gfi1 transcriptional repressor results in a novel form of neutropenia. Eur. J. Immunol. 42, 2395–2408 (2012). 25. Charmoy, M. et al. [nature.com]

  Recombinant human GMCSF was well tolerated, reversed neutropenia, eosinopenia and monocytopenia and reduced the number of secondary infections. [antimicrobe.org]

• Normocytic Anemia

  In laboratory tests, he had normochromic normocytic anemia and elevated ESR. He was initially diagnosed with pneumonia. [intjinfection.com]

• Leishmania Tropica

  tropica complex New world: L. braziliensis complex and L. mexicana complex L. braziliensis may also produce espundia, a destructive mucocutaneous form Human infection through bite of Phlebotomus sand fly (smaller than mosquitoes); rarely through blood [pathologyoutlines.com]

  Key words: Leishmania infantum / Leishmania major / Leishmania tropica / Epidemiology / Algeria / Libya / Morocco / Tunisia / Egypt © K. Aoun & A. [doi.org]

  FACTS: Leishmania tropica is a tropical parasite that is primarily transmitted to humans by the bite of the sandfly. It is found in most tropical and sub-tropical countries around the world. [giantmicrobes.com]

  Old World cutaneous leishmaniasis is caused mainly by Leishmania tropica, Leishmania major, and Leishmania aethiopica in the Mediterranean, Middle East, Africa, Central Asia, and Indian subcontinent. New World cutaneous ... [accessmedicine.mhmedical.com]

  Mebrahtu Y, Lawyer P, Githure J, Were JB, Muigai R, et al. (1989) Visceral leishmaniasis unresponsive to pentostam caused by Leishmania tropica in Kenya. [journals.plos.org]

The use of antiparasitic pentavalent antimonial like sodium stibogluconate and meglumine antimonate are the mainstay in the treatment of all forms of leishmaniasis [7]. Pentavalent antimonials have cure rate of 90%-97% for leishmaniasis. However, the liposomal form of Amphoteracin B is the drug of choice for visceral leishmaniasis [8].

The oral antineoplastic drug miltefosine has been advocated to halt the proliferation of leishmania in the cutaneous tissues [9]. In India, meltifosine has become the drug of choice for visceral leishmaniasis [10]. Other treatment options available for the cutaneous disease includes: cryotherapy, reconstructive surgery, local heat therapy and topical paromomycin preparations.

The localized cutaneous forms of leishmaniasis are expected to resolve within 3 to 6 months without therapy. The disseminated cutaneous form of leishmaniasis are often associated with treatment resistance and are extremely disfiguring to the face although mortality rates remains low.

The mucocutaneous forms are more disfiguring for it attacks the mid-facial structures like the palate, lips and the nose. Mortality is evident due to the secondary bacterial infection of the respiratory system. Visceral leishmaniasis is potentially serious and lethal especially in those with poor immune resistance and poor nutritional status.

Complications

The majority of the complications in leishmaniasis is due to the relative anemia, leukopenia and thrombocytopenia in patients. The following clinical conditions are the more common complications of leishmaniasis:

• Bacteremia or septicemia
• Bacterial coinfection like pneumonia and tuberculosis
• Splenomegaly which may lead to rupture
• Uncontrolled hemorrhage
• Disfigurement of the middle face
• Edema and hyperpigmentation in the late stage
• Nasopharyngeal tissue destruction

The primary reason of leishmaniasis transmission is the eventual migration of human population to the natural habitat of sandflies in the jungle because of urban expansion to the wild. There is a close correlation with leishmaniasis and poverty, malnutrition, the unavailability of vaccines, and the limited access of first line medical care.

Persons with AIDS have a 100 fold risk of acquiring leishmaniasis in endemic areas of the globe. Old world leishmaniasis is primarily caused by Leishmania donovani endemic in China, India and Bangladesh, Leishmania tropica in the Middle East and the Mediterranean and in Africa caused by Leishmania aethiopica. The new world leishmaniasis is dominated by Leishmania brazilienses in Central and South America and Leishmania chagasi in Central and South America.

Transmission of the disease through the bite of the sandfly is the most common mode of transmission but less common routes include congenital transfer, blood transfusion, sexual intercourse and sharing of infected needles, which only occurs in endemic countries [2].

Leishmaniasis is fairly rare in the United States with sporadic cases of cutaneous leishmaniasis found in southern Texas and Oklahoma bordering Mexico [3]. During the Persian Gulf War at least 400 US service men acquired cutaneous leishmaniasis from their tour of duty [4].

Approximately 1% of US forces serving the Western Asia are infected with the Old World leishmaniasis [5]. The World Health Organization (WHO) reports that there is an annual incidence of 220,000 cases of cutaneous Leishmaniasis and 58,000 cases of visceral forms occurring worldwide [6].

Males has double the risk of the disease compared to the females due to occupational exposures to the sandfly’s habitat. The adolescent and young adults are the more susceptible group in Colombia and Afghanistan while the infant group are more prone in Iran.

Leishmania is introduced to the human skin in its flagellated form (mastigote) from the salivary glands of the sandfly. When the protozoan enters the blood stream they lose their flagella and become an amastigote where a majority are extinguished by the body’s natural defense and the minority are engulfed by the macrophages where they multiply and evolve. The fast proliferation of the leishmania species within the cell incapacitates it till it explodes and releases the active form of the parasite (promastigote) to infect other healthy cells.

They have a predisposition in infecting the reticuloendothelial cells rendering the host vulnerable to any cell mediated immunity breach. Parasitized macrophages abound the spleen and the bone marrow. Engorgement of the vascular vessels of the spleen leads to enlargement. Bone marrow becomes hyperplastic and the hematopoetic tissues are subsequently replaced by the parasitized macrophages. The disseminated cutaneous spread of leishmaniasis is due to the relative anergy of the system to immunologically react to the protozoal antigen.

Like any parasitic vector-borne disease, leishmaniasis is best prevented by the prejudicial avoidance of the sandfly’s habitat especially in endemic regions.

The early diagnosis and treatment is still the most important guiding principle in the treatment of the disease. Vaccination against leishmania seems to be a promising option but may not offer adequate protection against the visceral forms. Insect repellants must always be applied to the skin to prevent insect bites.

Leishmaniasis is a disease caused by an intracellular protozoan parasite called Leishmania spp. transmitted through the bite of a sandfly (genus Phlebotomus).

Leishmaniasis is generally divided into two categories:

• Visceral leishmaniasis or Kala-azar caused by Leishmania donovani, Leishmania chagasi and Leishmania infantum presenting as low red and white blood cell count, fever and splenomegaly
• Mucocutaneous leishmaniasis or Espundia primarily caused by Leishmania braziliensis presenting as mucocutaneous nodule or ulcers on the site of sandfly bite.

Leishmaniasis may also be conveniently classified as to geographical origin. The Old World Leishmaniasis from Asia, Africa and Middle East and the New World Leishmaniasis occurring in Central and South America [1]. Latent disease may express after 2-6 months of incubation and may present with relapse after 10 years.

Patients bitten by the Phlebotomus sandfly must submit to immediate medical therapy to circumvent the advancement of the clinical course. Any potentially disfiguring lesions in the middle face must be brought in immediately for surgical evaluation and care. A patient infected with leishmania must take absolute care not to contract secondary infections because he is categorically immune-compromised.

1. World Health Organization. Leishmaniasis: the disease and its epidemiology. Accessed April 10, 2014
2. Cardo LJ, Rentas FJ, Ketchum L, Salata J, Harman R, Melvin W, et al. Pathogen inactivation of Leishmania donovani infantum in plasma and platelet concentrates using riboflavin and ultraviolet light. Vox Sang. Feb 2006; 90(2):85-91
3. Centers for Disease Control and Prevention. Parasites home: leishmaniasis. Resources for health professionals. 
4. Magill AJ, Grogl M, Gasser RA Jr, Sun W, Oster CN. Visceral infection caused by Leishmania tropica in veterans of Operation Desert Storm. N Engl J Med. May 13 1993; 328(19):1383-7.
5. Centers for Disease Control and Prevention. Update: Cutaneous leishmaniasis in U.S. military personnel--Southwest/Central Asia, 2002-2004. MMWR Morb Mortal Wkly Rep. Apr 2 2004; 53(12):264-5.
6. Alvar J, Cañavate C, Gutiérrez-Solar B, Jiménez M, Laguna F, López-Vélez R, et al. Leishmania and human immunodeficiency virus coinfection: the first 10 years. Clin Microbiol Rev. Apr 1997; 10(2):298-319.
7. World Health Organization. Essential leishmaniasis maps: cutaneous leishmaniasis.
8. Centers for Disease Control and Prevention. Parasites home: leishmaniasis. Epidemiology & risk factors. 
9. Investigational Drug Available Directly from CDC for the Treatment of Infections with Free-Living Amebae.MMWR Morb Mortal Wkly Rep. Aug 23 2013; 62(33):666.
10. Prasad R, Kumar R, Jaiswal BP, Singh UK. Miltefosine: an oral drug for visceral leishmaniasis. Indian J Pediatr. Feb 2004; 71(2):143-4.