The emergence of Leishmania major and Leishmania donovani in southern Turkey

Occupational exposure to malaria, leishmaniasis and arbovirus vectors in endemic regions: A systematic review

Vector-borne diseases, including dengue, leishmaniasis and malaria, may be more common among individuals whose occupations or behaviours bring them into frequent contact with these disease vectors outside of their homes. A systematic review was conducted to ascertain at-risk occupations and situations that put individuals at increased risk of exposure to these disease vectors in endemic regions and identify the most suitable interventions for each exposure. The review was conducted in accordance with PRISMA guidelines on articles published between 1945 and October 2021, searched in 16 online databases. The primary outcome was incidence or prevalence of dengue, leishmaniasis or malaria. The review excluded ecological and qualitative studies, abstracts only, letters, commentaries, reviews, and studies of laboratory-acquired infections. Studies were appraised, data extracted, and a descriptive analysis conducted. Bite interventions for each risk group were assessed. A total of 1170 articles were screened and 99 included. Malaria, leishmaniasis and dengue were presented in 47, 41 and 24 articles, respectively; some articles presented multiple conditions. The most represented populations were soldiers, 38% (43 of 112 studies); refugees and travellers, 15% (17) each; migrant workers, 12.5% (14); miners, 9% (10); farmers, 5% (6); rubber tappers and missionaries, 1.8% (2) each; and forest workers, 0.9% (1). Risk of exposure was categorised into round-the-clock or specific times of day/night dependent on occupation. Exposure to these vectors presents a critical and understudied concern for outdoor workers and mobile populations. When devising interventions to provide round-the-clock vector bite protection, two populations are considered. First, mobile populations, characterized by their high mobility, may find potential benefits in insecticide-treated clothing, though more research and optimization are essential. Treated clothing offers personal vector protection and holds promise for economically disadvantaged individuals, especially when enabling them to self-treat their clothing to repel vectors. Secondly, semi-permanent and permanent settlement populations can receive a combination of interventions that offer both personal and community protection, including spatial repellents, suitable for extended stays. Existing research is heavily biased towards tourism and the military, diverting attention and resources from vulnerable populations where these interventions are most required like refugee populations as well as those residing in sub-Saharan Africa.

Arthropod vectors of disease agents: their role in public and veterinary health in Turkiye and their control measures

Mosquitoes, sandflies, and ticks are hematophagous arthropods that pose a huge threat to public and veterinary health. They are capable of serving as vectors of disease agents that can and have caused explosive epidemics affecting millions of people and animals. Several factors like climate change, urbanization, and international travel contribute substantially to the persistence and dispersal of these vectors from their established areas to newly invaded areas. Once established in their new home, they can serve as vectors for disease transmission or increase the risk of disease emergence. Turkiye is vulnerable to climate change and has experienced upward trends in annual temperatures and rising sea levels, and greater fluctuations in precipitation rates. It is a potential hotspot for important vector species because the climate in various regions is conducive for several insect and acari species and serves as a conduit for refugees and immigrants fleeing areas troubled with armed conflicts and natural disasters, which have increased substantially in recent years. These people may serve as carriers of the vectors or be infected by disease agents that require arthropod vectors for transmission. Although it cannot be supposed that every arthropod species is a competent vector, this review aims to (1)illustrate the factors that contribute to the persistence and dispersal of arthropod vectors, (2)determine the status of the established arthropod vector species in Turkiye and their capability of serving as vectors of disease agents, and (3)assess the role of newly-introduced arthropod vectors into Turkiye and how they were introduced into the country. We also provide information on important disease incidence (if there's any) and control measures applied by public health officials from different provinces.

Autochthonous transmission of Leishmania donovani and Leishmania major with all the components of infection cycle at Europe's doorstep

OBJECTIVES

Leishmaniasis is a vector-borne disease and dogs may act as urban reservoirs. Turkey and most of the Mediterranean basin countries are endemic for leishmaniasis. In this study, it is aimed to report the autochthonous leishmaniasis cases, with all the components of the infection cycle (reservoir, vector, and the host) in a region close to Europe.

METHODS

Nine human and four canine autochthonous leishmaniasis cases were included in the study. Direct microscopy, culture methods, serological, and molecular tests were applied to the samples obtained from the cases.

RESULTS

VL and CL patients consisted of 2 L.infantum, 1 L. donovani, 2 L. tropica, and 2 L. tropica,1 L. major,1 L. infantum infected patients respectively. CanL cases were infected with L. infantum, L. donovani, L. tropica, and L. major.

CONCLUSIONS

All the cases were autochthonous cases located in Manisa province. As Greece and all the Mediterranean basin countries in Europe share competent vectors, it is concluded that the detection of all 4 species of Leishmania parasites in such proximity to Europe poses an important public health threat for Europe. This study reports all four species of Leishmania spp., including L. major and L.donovani in close proximity to continental Europe.

The current epidemiology of leishmaniasis in Turkey, Azerbaijan and Georgia and implications for disease emergence in European countries

Leishmania spp. are sand fly-borne protozoan parasites causing leishmaniasis in humans and animals. The aim of the study was to analyse the epidemiology of leishmaniasis in Turkey, Azerbaijan and Georgia from 2005 to 2020 and evaluate the associated risk for disease emergence in European countries. It is based on an analysis of WHO and OIE reported cases between 2005 and 2020, a review of scientific articles published in SCOPUS between 2009 and 2020 and a questionnaire survey to public health and veterinary authorities in these countries. Endemic Leishmania spp. include L. infantum in the three countries, L. major in Azerbaijan and Turkey and L. tropica and L. donovani in Turkey. Leishmaniasis is reported in humans, animals and sand flies and incidence is spatially and temporarily variable. In the southern Caucasus and particularly in Georgia, reported incidence of human visceral leishmaniasis by L. infantum remains high. However, whilst Georgia experienced a gradual decrease from >4.0 cases per 100,000 population in 2005-09 to 1.13 cases per 100,000 population in 2020, the period with highest incidence in Azerbaijan, which ranged between 0.40 and 0.61 cases per 100,000 population, was 2016-2019, and no cases have so far been reported for 2020. Visceral leishmaniasis in the Southern Caucasus affects mostly young children from deprived urban areas and its closely associated to canine leishmaniasis. Turkey reported cases of visceral leishmaniasis between 2005 and 2012 and in 2016 only, and incidence ranged between 0.02 and 0.05 per 100,000 population. In contrast, the reported annual incidence of cutaneous leishmaniasis in Turkey was much greater and peaked at 7.02 cases per 100,000 population in 2013, associated to imported cases from cutaneous leishmaniasis endemic Syria. Leishmaniasis by L. infantum in Azerbaijan and Georgia represents a regional public and animal health challenge that requires support to improve diagnosis, treatment and control. The unprecedented rise of cutaneous leishmaniasis and the spread of L. tropica and L. donovani in Turkey is an important risk factor for their emergence in Europe, especially in Mediterranean countries where competent vectors are widespread.

Determination of sand fly fauna and molecular detection of Leishmania in sand flies in Antalya Province, Southern Turkey

Visceral leishmaniasis (VL) and cutaneous leishmaniasis (CL) are diseases transmitted by infected female sand flies. Since the eradication of malaria in Turkey, CL is the main vector-borne disease in the country, with more than 2000 cases per year, making it a significant public health problem. The aims of this study were to carry out an entomological survey in Antalya Province, an endemic area for CL in the Mediterranean Region of Turkey, to identify sand fly fauna and to screen female specimens for the presence of Leishmania parasites (Leishmania infantum, L. tropica, L. major, and L. donovani) using molecular analysis. Sand flies were collected in 42 localities of seven districts in Antalya Province using CDC miniature light traps in two different periods, June 2012 and September 2013. The specimens were kept in 96% ethanol until the dissection was done. The head and genitalia of the specimens were cut for preparing individual slides for species identification. The rest of the body of female specimens was kept separately. The specimens were identified at the species level, and 27 pools were generated according to the locations and species for screening the presence of Leishmania. A commercial kit was used for DNA extractions. Real-time and conventional polymerase chain reaction (PCR) targeting the internal transcribed spacer region (ITS1) were then performed. In total, 1306 specimens comprising nine species belonging to the Phlebotomus genus were collected in the study region, with Phlebotomus neglectus/syriacus (38.82%) the most abundant, followed by P. alexandri (21.67%) and P. tobbi (20.44%). In the 27 pools, Leishmania infantum DNA was detected in four pools containing P. neglectus/syriacus and one pool containing P. tobbi. In conclusion, the sand fly fauna in the Antalya Province is diverse. The probable vector sand fly species are P. neglectus/syriacus and P. tobbi with high dominance (59.26%), which indicates a high risk of CL transmission. The data presented here may help to shed more light on the transmission cycles of the Leishmania parasite in this CL endemic area.

Seroprevalence and molecular detection of Leishmania spp. in cats of West Aegean Region, Turkey

Zoonotic visceral leishmaniasis is caused by protozoa of the genus Leishmania. Although dogs are considered to be primary reservoir hosts of Leishmania spp., several mammals, such as foxes, jackals and small rodents may also be hosts of different Leishmania spp. Previously, cats were considered as asymptomatic hosts of the parasite without acting as a reservoir. In recent years, there has been an increasing number of leishmaniasis cases in cats, especially in regions where the infection endemically occurs. This data indicate that cats are more likely to be one of the main reservoirs of Leishmania spp. rather than being a non-reservoir host. The aim of this study is to determine the prevalence of Leishmania spp. by molecular and serological techniques among owned and stray cats in four different cities located in western part of Turkey. A total of 386 blood and 301 serum samples were collected from cats in Western Turkey where leishmaniasis is endemic. Feline serum samples were tested by IFAT to detect IgG antibodies against Leishmania spp. antigens. Blood samples collected from 386 cats were examined by PCR for the presence of Leishmania spp. According to PCR results using RV1/RV2 primers, nine (2.3%) out of 386 samples were positive for Leishmania spp. Further PCR analysis using MC1/MC2 primers showed that one cat in Izmir was found to be infected with L. infantum/donovani complex. Sequence analysis revealed the presence of L. infantum, L. major and L. tropica among sampled cats in western part of Turkey. On the other hand, IFAT results indicated that an overall of 47 out of 301 (15.6%) cats that examined by PCR were found to have anti-Leishmania antibodies. Also, six of the seropositive cats were owned animals. The present study demonstrated that both owned and stray cats can be infected with Leishmania spp. and might be potential reservoirs for other animals and humans. Therefore, all communities living in or nearby endemic regions should be made aware of the role of cats as potential reservoirs of infection. In endemic regions, all animals should be protected against infection with insecticides and monitored routinely to control the spread of zoonotic visceral leishmaniasis.

Cutaneous Leishmaniasis due to Three Leishmania Species Among Syrian Refugees in Sanliurfa, Southeastern Turkey

Sanliurfa, a city in southeastern Turkey, is host to 477,166 Syrian refugees. The incidence of cutaneous leishmaniasis (CL) may be on the rise in areas affected by a refugee crisis, like Sanliurfa; thus, consequently, local uncommon species of Leishmania may be encountered in these regions. This might potentially make diagnosis and treatment more challenging over time. In this study, it was aimed to identify the causative agents of CL in clinical samples. A total of 154 patients (60 Syrian and 94 Turkish) who were diagnosed with CL via microscopical examination and PCR were enrolled this study. All of the samples were analyzed using internal transcribed spacer 1 genes, restriction fragment length polymorphism, DNA-sequencing, and phylogenetic analyses. In this study, Leishmania tropica was determined to be the predominant species in 140 of the patients (90.9%), followed by Leishmania major in 12 patients (7.8%), and Leishmania infantum in 2 patients (1.3%). Of the 94 Turkish patients, 94.7% were infected with L. tropica and 5.3% were infected with L. major, while none were infected with L. infantum. However, of the 60 Syrian patients, 85% were infected with L. tropica, 11.7% were infected with L. major, and 3.3% were infected with L. infantum. There was a significant association between the Leishmania species and the nations (Turkish-Syrian) (P < 0.001). The sequences were numbered from MH347941 to MH347953 and submitted to GenBank. This study confirmed that L. tropica, L. major, and L. infantum coexisted in Sanliurfa. This was the first time that the species L. infantum was reported among recent immigrants from Syria in Sanliurfa. Therefore, it is necessary to discriminate the Leishmania species for diagnosis, treatment, and controlled studies in hyper-endemic regions.

Modelling habitat suitability in Jordan for the cutaneous leishmaniasis vector (Phlebotomus papatasi) using multicriteria decision analysis

Cutaneous leishmaniasis (CL) is a zoonotic vector-borne neglected tropical disease transmitted by female Phlebotomine sand flies. It is distributed globally but a large proportion of cases (70-75%) are found in just ten countries. CL is endemic in Jordan yet there is a lack of robust entomological data and true reporting status is unknown. This study aimed to map habitat suitability of the main CL vector, Phlebotomus papatasi, in Jordan as a proxy for CL risk distribution to (i) identify areas potentially at risk of CL and (ii) estimate the human population at risk of CL. A literature review identified potential environmental determinants for P. papatasi occurrence including temperature, humidity, precipitation, vegetation, wind speed, presence of human households and presence of the fat sand rat. Each predictor variable was (a) mapped; (b) standardized to a common size, resolution and scale using fuzzy membership functions; (c) assigned a weight using the analytical hierarchy process (AHP); and (d) included within a multicriteria decision analysis (MCDA) model to produce monthly maps illustrating the predicted habitat suitability (between 0 and 1) for P. papatasi in Jordan. Suitability increased over the summer months and was generally highest in the north-western regions of the country and along the Jordan Valley, areas which largely coincided with highly populated parts of the country, including areas where Syrian refugee camps are located. Habitat suitability in Jordan for the main CL vector-P. papatasi-was heterogeneous over both space and time. Suitable areas for P. papatasi coincided with highly populated areas of Jordan which suggests that the targeted implementation of control and surveillance strategies in defined areas such as those with very high CL vector suitability (>0.9 suitability) would focus only on 3.42% of the country's total geographic area, whilst still including a substantial proportion of the population at risk: estimates range from 72% (European Commission's Global Human Settlement population grid) to 89% (Gridded Population of the World) depending on the human population density data used. Therefore, high impact public health interventions could be achieved within a reduced spatial target, thus maximizing the efficient use of resources.

Entomological Survey for the Detection of Sand Fly Fauna and Vector Species in the Cutaneous Leishmaniasis Endemic Area in East Mediterranean Region of Turkey, Mersin Province

Cutaneous (CL) and visceral (VL) forms of leishmaniasis, transmitted by sand flies, are seen in all countries located in Mediterranean Basin including Turkey. In this study, we aimed to conduct an entomological survey for the detection of sand fly fauna and vector species in Mersin province, one of the important endemic areas for CL in Turkey. In total, 912 sand fly specimens were collected in 2010 and 2011 using CDC light traps. Nine Phlebotomus (Diptera: Psychodidae) and three Sergentomyia (Diptera: Psychodidae) species were detected. Of the collected Phlebotomus sand flies, P. sergenti Parrot, 1917 (30.1%) was the most dominant followed by P. alexandri Sinton, 1928 (18.2%), P. neglectus/syriacus Tonnoir Adler (12.0%), P. tobbi Adler & Theodor, 1930 (11.7%), and P. papatasi Scopoli, 1786 (10.2%), while S. minuta Rondani, 1843 (11.3%) was the dominant species among Sergentomyia. During the field work in 2011, female specimens (n = 81) were screened for the presence of Leishmania promastigotes by midgut dissection, and all were found negative. The rest of the collected female specimens (n = 334) were pooled according to species (P. alexandri, P. neglectus/syriacus, P. papatasi, P. sergenti, P. simici, and P. tobbi) and location (Mut, Silifke, and Anamur). In total, 29 pools were generated and real-time ITS1 PCR assay was performed to detect and identify natural Leishmania Ross, 1903 (Kinetoplastida: Trypanosomatida) infection. Two pools, both from Mut town, containing P. sergenti specimens were found positive and Leishmania tropica Ross, 1903 was identified as an infectious agent for both pools. In conclusion, the sand fly fauna was determined in an endemic area for CL. The detection of L. tropica DNA in P. sergenti specimens showed the possible vectorial role of this species in Mersin province.

First molecular detection and identification of Leishmania species in small wild rodents from Turkey

Leishmaniasis is a parasitic disease infecting animals and humans. Two clinical forms (Visceral and cutaneous leishmaniasis) and four species are reported to be present in Turkey. Several studies have investigated canine and human leishmaniasis in Turkey but no study was performed to screen the infection among wild rodents, so far. The present study aims to investigate the role of small wild rodents as reservoir animals for Leishmania spp. in different regions of Turkey. Formalin-preserved tissue samples (spleen, liver, lung) of 712 rodents from 30 provinces were screened for the presence of Leishmania spp. DNA. Before DNA extraction, tissues were dried, rehydrated, and homogenated. Leishmania screening in rodent tissues and species determination was performed with a combination of real-time kDNA and ITS1 polymerase chain reaction protocols. Eight (1.12%) out of 712 animals were found to be positive for Leishmania spp. DNA and species typing revealed five L. infantum, two L. tropica and one L. major among positives. Leishmania major and L. infantum DNA were detected in Apodemus spp. from Zonguldak province located in the Western Black Sea Region, while L. tropica DNA was found in Meriones sp. and Gerbillus dasyurus from Adana and Hatay provinces located in Eastern Mediterranean Region of Turkey. The present study is first to report natural infection of L. infantum, L. major and L. tropica in small wild rodents in Turkey, suggesting their possible roles as reservoirs. Further studies are needed for planning epidemiological studies and also for developing rodent control measures in risky endemic areas to break the transmission cycle.

Trend of Cutaneous Leishmaniasis in Jordan From 2010 to 2016: Retrospective Study

Background

Cutaneous leishmaniasis (CL) is endemic in the Middle East, with countries such as Syria reporting high incidence rates.

Objective

This study aimed to assess the trends in the incidence of cutaneous leishmaniasis (CL) in Jordan from 2010 to 2016.

Methods

This retrospective study included all cases of CL that had been reported to the Leishmaniasis Surveillance System in the Department of Communicable Diseases at the Jordan Ministry of Health during the period from 2010 to 2016. A total of 1243 cases were reported and met the case definition.

Results

A total of 1243 cases (60.65% [754/1243] males and 39.34% [489/1243] females) were diagnosed during the study period. Of this sample, 233 patients (19.13%) were aged <5 years old, 451 (37.03%) were aged between 5-14 years old, 190 (15.60%) were aged between 15-24 years old, and 344 (28.24%) were aged ≥25 years old. Of those, 646 (51.97%) were Jordanians and 559 (44.97%) were Syrians. The average annual incidence rate of 1.70 per 100,000 people between 2010 and 2013 increased to 3.00 per 100,000 people in the years 2014 to 2016. There was no difference in incidence rates between Jordanians and Syrian refugees between 2010 and 2012. After 2012, the incidence rate increased significantly among Syrian refugees from 1.20 per 100,000 people in 2012 to 11.80 per 100,000 people in 2016. On the contrary, the incidence rate did not change significantly among Jordanians.

Conclusions

The incidence rate of leishmaniasis in Jordan has increased in the last three years because of the influx of Syrian refugees into Jordan. A massive effort toward reservoir and vector control, along with actively pursuing diagnosis in endemic foci, will be helpful. Proper and studious reporting of cases is also a necessity for the eradication of this disease.

Refugees at the Crossroads of Continents: A Molecular Approach for Cutaneous Leishmaniasis Among Refugees in Turkey

PURPOSE

Due to mass population movements driven by internal conflicts and wars, cutaneous leishmaniasis (CL) is becoming increasingly important in Turkey. This study is aimed at determining the clinical aspects, diagnosis and genotyping of CL patients coming to Turkey from abroad.

METHODS

In our study, the clinical materials obtained from the patients or sent for diagnostic purposes from other centers to our laboratory between years 2012 and 2016 were assessed retrospectively. In total, there were 38 patients from Syria, Iraq, Afghanistan, Iran, and Turkmenistan.

RESULTS

29 (76%), 28 (73%) and 33 (87%) samples were positive by light microscopy, Novy-McNeal-Nicolle(NNN), and enriched medium, respectively. By ITS-1 gene region PCR, 31 (81%) of the cases were positive. 35 of the patients were tested positive by at least one of the diagnostic methods. By genotyping, 21 Leishmania tropica, 8 Leishmania major, 3 Leismania infantum, 2 Leishmania donovani, and 1 Leishmania aethopica were detected.

CONCLUSION

This study is aimed at informing the clinicians working in the field for the import CL cases and recording the changing epidemiological features of CL in the region as well as discussing the possible focus for L. aethiopica infection which has not been shown in the region before.

The Geographical Distribution of Cutaneous Leishmaniasis Causative Agents in Iran and Its Neighboring Countries, A Review

Leishmania tropica and Leishmania major are both the main cause of anthroponotic (ACL) and zoonotic cutaneous leishmaniasis (ZCL), respectively, in the Old World. Leishmania infantum and Leishmania donovani, which are important causes of visceral leishmaniasis, have also occasionally been reported in CL patients. The present study investigates the current distribution of causative species of CL in Iran and neighboring countries in the Middle East. There has been expansion of L. tropica into new urban and rural foci in Iran, with well-documented cases of visceralization, a substantial increase of CL in Syria, and the emergence of new foci and outbreaks in Turkey and Iraq, especially due to L. major. Civil war in Syria and Iraq, population movement, poverty, and climatic change play important roles in the changing CL distribution in this region. Control programs should adopt a multidisciplinary approach based on active surveillance and case finding, especially in vulnerable refugee populations, determination of hazard maps for CL hot points using GIS and other advanced technology, the free distribution of drugs, rodent control, and greater community engagement in poor and marginalized populations. Comprehensive molecular studies that could show the species and strains of Leishmania in different areas of each country can give a better view from the distribution of CL in this region.

Demographical and population dynamics impact on public health of cutaneous Leishmaniasis in Al-Madinah Almonawra, Saudi Arabia

Background

A cross-sectional study conducted in Al-Madinah Almonawra in KSA held during the period from March 2014–March 2015.

Aim of the study

This study aimed at analyzing the effect of population dynamics on the current situation of cutaneous leishmaniasis in Al-Madinah Almonawarah area, a holy city that attracts millions of muslims annually.

Methodology

Epidemiological and clinical data were collected by especial questionnaire and laboratory specimens were collected using skin scraping and needle aspiration. Staining and direct microscopy were done. LST was conducted. Analysis was done using SPSS program.

Results

The study included 164 patients, all of them were men. Saudi nationality comprised around 20% of the study group, the majority were Egyptians, 26.2%, followed by Pakistani, 21.3%.

Conclusion

The presence of non-Saudi nationality as foreign workers, immigrants and refugees has worsened the current situation of the disease.

Leishmaniasis in Istanbul; A new epidemiological data about refugee leishmaniasis

Leishmania is an intracellular parasite, which is transmitted by the bite of infected female Phlebotominae sand flies. Turkey is a crossroad between Europe and Asia that makes it important in terms of epidemiology. In the present study, we aimed to evaluate Leishmania infection among non-autochthonous patients admitted to Health Sciences University, Dr. Sadi Konuk Research and Training hospital between 2014-2018. Slides were prepared by sampling the edge of the lesions for each patient. Microscopical examination was performed after staining procedures. After microscopical examination slides were washed and DNA extraction was performed. ITS-1 real-time PCR was performed to identify the species of the causative agents. Demographic data were recorded for each patient. Also number, type and location of the lesions were recorded. Totally 13 patients were included in this. Majority (12/13) of them were found to be infected with L. tropica, while one patient was infected with L. infantum. Two of the lesions were wet type and 11 of them were dry type lesions. Several papers were published recently about leishmaniasis in Turkey but to best of our knowledge, this is the first study reporting refugee leishmaniasis in İstanbul.

The increase in neglected cutaneous leishmaniasis in Gaziantep province of Turkey after mass human migration

Outbreaks of Cutaneous Leishmaniasis (CL) due to war-related factors have been reported in different areas in Turkey and Syria. CL has become the most serious of the infectious diseases which have been reported in Gaziantep in southeast Turkey, during the last three years due to the influx of Syrian refugees. The present research involves an analytical cross-sectional epidemiological study of CL cases diagnosed in the Gaziantep Leishmaniasis Diagnosis and Treatment Center. The patient demographic data, the location of the lesions, the number of the lesions, the duration of the lesions, and the treatment of the lesions are included. The diagnosis of CL was made by microscopic examination of smears in all cases, and 81.1% (900/1110) of which were found to be positive. Out of 900 CL patients, 93.8% (845/900) were Syrian citizens and 6.2% (55/900) were Turkish citizens. The disease was more frequent in females with 53.5% (482/900) and in the age group between 0-20 years with 68.3% (615/900). Distribution of lesions in the body showed that the face was the most affected location with 37% (333/900), and the generation time of lesions was 0-6 months with 71.2% (641/900). 94.7% (852/900) of the CL patients healed without relapse, and 5.3% (48/900) of the CL patients relapsed. CL patients have re-emerged in Gaziantep, located in the southeast of Turkey, as a result of Syrian refugees. The increase in CL frequency is alarming and requires control and prevention measures in highly infected areas including this region.

Cloning and molecular characterization of thiol-specific antioxidant gene of Leishmania tropica Turkey isolate

Background/aim

Thiol-specific antioxidant (TSA) protein is one of the most promising molecules among candidates for vaccine against cutaneous leishmaniasis. It was found to be significantly protective against different Leishmania species. In this study, cloning and molecular characterization of thiol-specific antioxidant gene of L. tropica Turkey isolate (LtTSA) were aimed.

Materials and methods

LtTSA was amplified by PCR using the specific primers of TSA gene and cloned into the pcDNA3.1 vector. The cloning was confirmed by PCR screening, restriction enzyme reactions, and DNA sequence analysis. Finally, three-dimensional structure and antigenic properties of the protein encoded by the LtTSA were determined

Results

Six hundred base pair bands belonging to LtTSA were shown with electrophoresis. It was found that LtTSA and its encoded protein have high similarity with different Leishmania species. LtTSA protein consisting of 199 amino acids was found to have 7 different antigenic regions.

Conclusion

LtTSA and its encoded TSA protein were found to be highly immunogenic and similar to TSA proteins previously tested as a vaccine candidate.

The current clinical and geographical situation of cutaneous leishmaniasis based on species identification in Turkey

Leishmaniases are a group of vector-borne diseases caused by the members of Leishmania genus, and there are three main clinical forms of the infection as visceral, cutaneous, and mucocutaneous. Cutaneous leishmaniasis is a growing public health problem in Turkey due to increasing detection of autochthonous cases caused by L. major and L. donovani in some regions in addition to Syrian imported cases. For this reason, we aimed to evaluate the current epidemiological situation of CL in the view of causative agents and their geographical distribution throughout Turkey. The samples were collected from 356 CL patients admitted to different centers in 18 provinces between January 2013 and December 2016. Direct microscopy, culture (regular and enriched NNN) and molecular techniques (real-time ITS1 PCR and hsp70 PCR/sequencing) were performed. By molecular techniques, 299, 28, 19 and 10 isolates/clinical samples were identified as L. tropica, L. major, L. infantum and L. donovani, respectively. Most of the patients (65.73%) had one lesion usually on their face/head. Dry-nodular type lesions (n = 291) were mainly associated with L. tropica while L. major was mainly found related to wet-ulcerative ones. Leishmaniasis recidivans was also detected in 2.52% among 356 patients. L. tropica was detected as most widespread species causing CL in Turkey. L. infantum and L. major was also found in one third of the provinces. Enriched NNN culture was worked well for isolating the parasite and 346 isolates were successfully grown and stored in liquid nitrogen. The comparison of all diagnostic techniques showed that the parasitological positivity rate could increase if the combination of direct microscopy and real-time ITS1 PCR is used. Besides well-known anthroponotic L. tropica cases, the increasing detection of CL cases caused by zoonotic species, L. infantum and L. major, is one of the most important findings in the present study. In our opinion to ensure timely and accurate diagnosis, proper treatment and countrywide effective control of CL in Turkey a systematic approach is needed on the base of information about characteristics of lesions and patients and epidemiological features of the disease.

Nonconventional opponents: a review of malaria and leishmaniasis among United States Armed Forces

As the United States military engage with different countries and cultures throughout the world, personnel become exposed to new biospheres as well. There are many infectious pathogens that are not endemic to the US, but two of particular importance are Plasmodium and Leishmania, which respectively cause malaria and leishmaniasis. These parasites are both known to cause significant disease burden in their endemic locales, and thus pose a threat to military travelers. This review introduces readers to basic life cycle and disease mechanisms for each. Local and military epidemiology are described, as are the specific actions taken by the US military for prevention and treatment purposes. Complications of such measures with regard to human health are also discussed, including possible chemical toxicities. Additionally, poor recognition of these diseases upon an individual's return leading to complications and treatment delays in the United States are examined. Information about canine leishmaniasis, poorly studied relative to its human manifestation, but of importance due to the utilization of dogs in military endeavors is presented. Future implications for the American healthcare system regarding malaria and leishmaniasis are also presented.

Leishmaniasis

Leishmaniasis is a poverty-related disease with two main clinical forms: visceral leishmaniasis and cutaneous leishmaniasis. An estimated 0·7-1 million new cases of leishmaniasis per year are reported from nearly 100 endemic countries. The number of reported visceral leishmaniasis cases has decreased substantially in the past decade as a result of better access to diagnosis and treatment and more intense vector control within an elimination initiative in Asia, although natural cycles in transmission intensity might play a role. In east Africa however, the case numbers of this fatal disease continue to be sustained. Increased conflict in endemic areas of cutaneous leishmaniasis and forced displacement has resulted in a surge in these endemic areas as well as clinics across the world. WHO lists leishmaniasis as one of the neglected tropical diseases for which the development of new treatments is a priority. Major evidence gaps remain, and new tools are needed before leishmaniasis can be definitively controlled.

Infectious disease profiles of Syrian and Eritrean migrants presenting in Europe: A systematic review

BACKGROUND

In the past decade, a large influx of migrants presented in Europe. Their country of origin was mainly either Syria or Eritrea. Public health institutions in host countries in Europe are challenged to screen and care for migrant populations with regard to infectious diseases.

METHODS

We performed a systematic literature review (according to PRISMA guidelines) to define the infectious disease profile of migrants originating in Syria and Eritrea.

RESULTS

The search resulted in 825 papers of possible relevance for infectious diseases in migrants from Syria, of which, after screening, we included 35 in the systematic review. A further 265 papers of possible relevance for infectious diseases in Eritrean migrants were screened, of which we included 27 in the systematic review. In migrants from Syria, leishmaniasis was the most frequently reported infectious disease. In addition, colonisation with drug resistant, Gram-negativ bacteria was reported. In the Eritrean migrants the infectious disease most described in the selected papers was louse-borne relapsing fever. Other frequently reported infectious diseases were scabies and Plasmodium vivax malaria.

CONCLUSION

Our systematic analysis defines the profiles of infectious diseases for migrants from Syria and Eritrea and serves as an evidence base for public health screening and care of presenting migrants.

Phlebotomine sand flies (Diptera: Psychodidae) in the Greek Aegean Islands: ecological approaches

BACKGROUND

Blood-sucking phlebotomine sand flies are the vectors of the protozoan parasites Leishmania spp. Different Phlebotomus species transmit different Leishmania species causing leishmaniases which are neglected diseases emerging/reemerging in new regions. Thirteen sand fly species, ten belonging to the medically important genus Phlebotomus and three belonging to Sergentomyia are known in Greece. An increasing number of human and dog cases are reported each year from all parts of the country including the Aegean Islands. However, no previous study has been conducted on the sand fly fauna on the islands, except for Rhodes and Samos. The aim of this study was to investigate sand fly species in eleven small Aegean islands; to understand species-specific relationships with environmental and climatic factors and to compare sand fly community parameters among islands. A risk analysis was carried out for each species using climatic and environmental variables.

RESULTS

Nine sand fly species: Phlebotomus neglectus, P. tobbi, P. similis, P. simici, P. perfiliewi, P. alexandri, P. papatasi, Sergentomyia minuta and S. dentata, were collected from the islands studied. Phlebotomus (Adlerius) sp. and Sergentomyia sp. specimens were also collected but not identified to the species level. There was a positive effect of distance from the sea on the abundance of P. neglectus, S. minuta and S. dentata, and a negative effect on the abundance of P. tobbi, P. simici and P. similis. In general, temperature preferences of sand fly populations were between 21 and 29 °C. Nevertheless, there were significant differences in terms of temperature and relative humidity preference ranges among species. The most important species found, P. neglectus, was indisputably the most adapted species in the study area with a very high reaction norm, favoring even the lower temperature and humidity ranges. Overall, the sand fly fauna in the islands was very rich but there were differences in species diversity, as indicated by the values of the Shannon-Wiener index, along with evenness and richness of the sand fly fauna between the islands and altitude ranges in the islands.

CONCLUSIONS

The study indicated that the Greek Aegean Islands, however small, maintain a rich sand fly fauna. This includes important vectors of Leishmania spp. representing a risk for parasite transmission to humans and dogs along with the danger of maintaining new Leishmania spp. if introduced to the area.

Cutaneous Leishmaniasis - A Case Series from Dresden

Leishmaniasis is world-wide one of the most common infectious disorders caused by protozoa. Due to the climate change, there is a risk of further spread of the disease to central and northern Europe. Another important issue is the high number of refugees from Syria since Syria is one of the hot spots of Old World leishmaniasis. We report on single-centre experience with leishmaniasis in the capital of Saxony, Dresden, during the years 2001 to 2017. We noted a substantial increase in the last five years. Once a very rare exotic disorder in Germany, cutaneous leishmaniasis has become a reality and physicians should be aware of it. A significant number of cases are from Syrian refugees; other cases had been acquired by tourists in the Mediterranean region!

Molecular identification of Leishmania spp. isolates causes cutaneous leishmaniasis (CL) in Sanliurfa Province, Turkey, where CL is highly endemic

Cutaneous leishmaniasis (CL) is an important public health problem in Turkey. CL has been most frequently seen in Sanliurfa. There is an expectation of increase in the population of leishmaniasis cases with the influence of Syrian refugees arriving in Turkey. In this study we aimed to diagnosis of CL and identifying of parasite from Leishmania isolates by using ITS 1 PCR RFLP. Samples were collected from 135 CL patients in Sanliurfa. After the specimens were inoculated in medium NNN, the ones which were cultures positive were cultivated in RPMI 1640 followed by PCR-RFLP. Genomic DNA was extracted phenol-chloroform procedure. Samples were examined by using ITS 1 PCR followed by RFLP analysis. Our results indicated that two species, L. tropica (132 samples) and L. major (3 samples), are responsible for cutaneous leishmaniasis in Sanlıurfa. Our study is the first scientific study in which it is reported molecular analyses of cutaneous leishmaniasis cases caused by L. major in Sanliurfa in Southestern Anatolia Region. Because CL cases caused by L.major are detected in our study, it is considered that genotyping is important for diagnosis of Leishmania and following change of epidemiology.

Wing morphology variations in a natural population of Phlebotomus tobbi Adler and Theodor 1930

Cutaneous leishmaniasis (CL) is highly endemic in the Cukurova region, located on the crossroads of main refugee routes from the Middle East to Europe on the eastern Mediterranean part of Turkey. Our purpose was to investigate the phenotypic variation of Phlebotomus tobbi, the known vector of CL in the region, during one active season. Sand flies and microclimatic data were collected monthly from May to October, 2011, from five locations in six villages in the study area. A geometric morphometric approach was used to investigate wing morphology. Shape analyses revealed that males collected in May and June comprised one group, while specimens collected in August, September, and October formed a second group. Specimens from July were found to be distributed within these two groups. A similar distribution pattern was observed for females, but specimens from October were represented as the third district group. Significant size variation was detected for both sexes between months. Wing size and temperature were negatively correlated for females, but there was no temperature effect for males. Wing size of both sexes was increased in correlation to increasing relative humidity. Males were found to have smaller wings with increasing population density.

Leishmaniasis in Turkey: Visceral and cutaneous leishmaniasis caused by Leishmania donovani in Turkey

In Turkey, the main causative agents are Leishmania tropica (L. tropica) and Leishmania infantum (L. infantum) for cutaneous leishmaniasis (CL) and L. infantum for visceral leishmaniasis (VL). In this study, we investigated leishmaniasis cases caused by L. donovani and established animal models for understanding its tropism in in vivo conditions. Clinical samples (lesion aspirations and bone marrow) obtained from CL/VL patients were investigated using parasitological (smear/NNN) and DNA-based techniques. For species identification, a real time ITS1-PCR was performed using isolates and results were confirmed by hsp70 PCR-N/sequencing and cpb gene PCR/sequencing in order to reveal Leishmania donovani and Leishmania infantum discrimination. Clinical materials from CL and VL patients were also inoculated into two experimental groups (Group CL and Group VL) of Balb/C mice intraperitoneally for creating clinical picture of Turkish L. donovani strains. After 45days, the samples from visible sores of the skin were taken, and spleens and livers were removed. Measurements of the internal organs were done and touch preparations were prepared for checking the presence of amastigotes. The strains were isolated from all patients and amastigotes were seen in all smears of the patients, and then isolates were immediately stored in liquid nitrogen. In real time ITS1-PCR, the melting temperatures of all samples were out of range of L. infantum, L. tropica and L. major. Sequencing of hsp70 PCR-N showed that all isolates highly identical to previously submitted L. donovani sequences in GenBank, and cpb gene sequencing showed five isolates had longer cpbF allele, whereas one isolate contained a mixed sequence of both cpbF and cpbE. All mice in both experimental groups became infected. Compared to controls, the length and width of both liver and spleen were significantly elevated (p<0.001) in both groups of mice. However, the weight of the liver increased significantly in all mice whereas the weight of spleen increased only in VL group. Amastigotes were also seen in all touch preparations prepared from skin sores, spleen and liver. L. donovani strain was isolated from autocutaneous a VL patient first time in Turkey. Animal models using clinical samples were successfully established and important clinical differences of the isolated strains were observed.

Phlebotomine sand fly-borne pathogens in the Mediterranean Basin: Human leishmaniasis and phlebovirus infections

Pathogens transmitted to humans by phlebotomine sand flies are neglected, as they cause infectious diseases that are not on the priority list of national and international public health systems. However, the infections caused by protozoa of the Leishmania genus and viruses belonging to the Phlebovirus genus (family Phenuiviridae)—the most significant group of viruses transmitted by sand flies—have a relevant role for human pathology. These infections are emerging in the Mediterranean region and will likely spread in forthcoming decades, posing a complex threat to human health. Four species and 2 hybrid strains of Leishmania are pathogenic for humans in the Mediterranean Basin, with an estimated annual incidence of 239,500–393,600 cases of cutaneous leishmaniasis and 1,200–2,000 cases of visceral leishmaniasis. Among the phleboviruses, Toscana virus can cause neuroinvasive infections, while other phleboviruses are responsible for a typical “3-day fever”; the actual incidence of Phlebovirus infections in the Mediterranean area is unknown, although at least 250 million people are exposed. Here, we reviewed the current literature on epidemiology of sand fly–borne infections in the Mediterranean Basin, with a focus on humans. Our analysis indicates the need for increased public health activities directed to determine the disease burden of these infections as well as to improve their surveillance. Among the emerging challenges concerning sand fly–borne pathogens, the relationships between sand fly–borne protozoa and viruses should be considered in future studies, including epidemiological links between Leishmania and phleboviruses as well as the conditional capacity for these pathogens to be involved in interactions that may evolve towards increased virulence.

Molecular screening of Leishmania spp. infection and bloodmeals in sandflies from a leishmaniasis focus in southwestern Turkey

Leishmaniasis is an arthropod-borne disease that affects approximately 2 million people worldwide annually. The aims of this study were to detect the presence of Leishmania (Kinetoplastida: Trypanosomatidae) DNA and the feeding preferences of probable vector species in an endemic focus of Leishmania infantum in Turkey. Entomological sampling was performed in August and October 2015 in Aydın province, where cases of human and canine leishmaniasis have been reported previously. A total of 1059 sandfly specimens comprising nine species belonging to two genera, Phlebotomus and Sergentomyia (both: Diptera: Psychodidae), and five subgenera of the Phlebotomus genus (Phlebotomus, Paraphlebotomus, Larroussius, Adlerius and Transphlebotomus) were collected in five villages. Among all Phlebotomus specimens, Phlebotomus neglectus (39%) was noted as the most abundant species, followed by Phlebotomus tobbi (18%). Leishmania DNA was detected in pools from P. neglectus, P. tobbi and Sergentomyia dentata by kDNA polymerase chain reaction (PCR). Leishmania DNA from Phlebotomus specimens was identified as L. infantum, but Leishmania DNA from Sergentomyia spp. could not be identified to species level by ITS-1 real-time PCR. The detection of Leishmania DNA in wild-caught P. neglectus and the high percentage (24.2%) of human DNA in engorged specimens suggests that P. neglectus is probably an important vector species for L. infantum in Aydın province.

Genotyping Leishmania promastigotes isolated from patients with cutaneous leishmaniasis in south-eastern Turkey

Objective

Cutaneous leishmaniasis (CL) is a significant disease in south-eastern Anatolia because it is prevalent among Syrian refugees. We identified the causative Leishmania species in CL patients using molecular methods.

Methods

Novy–MacNeal–Nicolle medium was inoculated with aspirated fluid from suspected CL lesions and tested for amastigotes with Giemsa staining. PCR amplified the internal transcribed spacer 1 (ITS1) of the Leishmania genome in cultures containing Leishmania promastigotes from 100 patients, which were genotyped with a restriction fragment length polymorphism (RFLP) analysis. A phylogenetic tree was constructed from ITS1 sequences of 95 culture fluid samples from these patients.

Results

Leishmania amastigotes were detected in 92% of cultures with growth. Leishmania promastigotes were typed as Leishmania tropica with both PCR–RFLP and sequencing.

Conclusions

Identification of L. tropica as the causative agent of CL in our region allows the clinical course to be predicted, and guides treatment decisions and preventive measures.

Assessment of diagnostic doses for widely used synthetic pyrethroids (Deltamethrin & Permethrin) in an endemic focus of leishmaniasis in Turkey

Background

Leishmania is a group of parasitic flagellated protozoons, which are transmitted by female sand flies and produces health problems in humans and also in wild and domestic animals. So far, 25 Phlebotomus and 4 Sergentomyia species were recorded in Turkey including proven or possible vectors of Leishmania spp. As no single insecticide susceptibility test was conducted targeting the sand flies in Turkey, we aimed to determine the diagnostic dose against two commonly used synthetic pyrethroids (deltamethrin and permethrin) in a hyperendemic area for leishmaniasis.

Methods

Sand flies were collected from villages of Adana in 2–4 September 2013 using Centers for Disease Control and Prevention (CDC) light traps and transferred to the laboratory. The World Health Organisation tube test method was conducted using self-prepared filter papers with different concentrations. In order to determine the diagnostic dose, lethal doses (LD) were calculated by EPA Probit Analysis. Sand flies used in the experiments were dissected, mounted and identified.

Results

For the lowest (0.025 %) and highest dose of permethrin (0.5 %), the mortality rate was recorded as 52.6 % and 100 % by the end of 24-h period and the diagnostic dose was recorded as 0.36 %. The mortality rate for lowest (0.0025 %) and highest (0.05 %) doses of deltamethrin was recorded as 54.8 % and 100 %. The diagnostic dose of deltamethrin was determined as 0.9 %.

Conclusion

An insecticide susceptibility study was conducted in Turkey for the first time and effective doses were determined by calculating the LDs. According to presented results, the wild population of sand flies collected from a hyper-endemic region of Adana Province is still susceptible to deltamethrin and permethrin.

Profile of illness in Syrian refugees: A GeoSentinel analysis, 2013 to 2015

Screening of 488 Syrian unaccompanied minor refugees (< 18 years-old) in Berlin showed low prevalence of intestinal parasites (Giardia, 7%), positive schistosomiasis serology (1.4%) and absence of hepatitis B. Among 44 ill adult Syrian refugees examined at GeoSentinel clinics worldwide, cutaneous leishmaniasis affected one in three patients; other noteworthy infections were active tuberculosis (11%) and chronic hepatitis B or C (9%). These data can contribute to evidence-based guidelines for infectious disease screening of Syrian refugees.

Pediatric Cutaneous Leishmaniasis in an Endemic Region in Turkey: A Retrospective Analysis of 8786 Cases during 1998-2014

BACKGROUND

Cutaneous leishmaniasis (CL) is a major public health concern in Turkey and Sanliurfa represents the most endemic city in Turkey. Although children are most commonly affected by CL, detailed studies of pediatric CL in Turkey are lacking.

METHODOLOGY/PRINCIPAL FINDINGS

In this report we retrospectively evaluated clinical and epidemiological data of 8786 pediatric CL cases, and how children respond to antimonial therapy. CL was observed most frequently in children between 6-10 years old. Interestingly this group showed shorter duration of disease and smaller lesions compared to 0-5 year and 11-15 year old groups. Females were more affected in all groups. Lesion localization and types varied among groups, with 0-5 year old presenting head/neck and mucosal lesions, and more often suffered from recidivans type, this could be associated to the longest duration of the disease in this group. Eleven-15 year old group showed fewer lesions in the head/neck but more generalized lesions. Evaluation of treatment response revealed that intra-lesional treatment was preferred over intramuscular treatment. However, 0-5 year old received intramuscular treatment more often than the other groups. Furthermore, the majority of 0-5 year old group which received intra-lesional treatment did not received subsequent intra-lesional cycles, as did children in the range of 6-15 years old.

CONCLUSIONS/SIGNIFICANCE

We report an increase in pediatric CL patients within the last four years. Analysis of pediatric CL patients by age revealed significant differences in CL progression. The data suggest that children between 0-5 years old responded better than other groups to intralesional treatment, since they received more often a single cycle of IL treatment, although follow up observation is required since they were more prone to develop recidivans. Eleven-15 year old patients comprise the largest percentage of patients receiving two or three cycles of intralesional treatment, suggesting that this group did not respond efficiently to intralesional treatment and highlighting the need for more effective therapeutic strategies against CL.

Seroprevalence of Leishmania infection and molecular detection of Leishmania tropica and Leishmania infantum in stray cats of İzmir, Turkey

Leishmaniasis caused by more than 20 species of genus Leishmania is transmitted by the bite of infected phlebotomine sand flies. The studies on Leishmania infection in cats is very few in Turkey and therefore we aimed to screen stray cats living in city of İzmir located in western Turkey using nested PCR targeting kinetoplast DNA and serological techniques (ELISA and IFA). Leishmania DNA positive samples were also studied by ITS1 real time PCR. Whole blood and serum samples were obtained from stray cats (n: 1101) living in different counties of İzmir. In serological assays, a serum sample was considered positive in 1:40 dilution in IFA and for ELISA a serum sample was accepted positive when the absorbance value (AV) exceeded the mean AV + Standard Deviation (SD) of the negative control serum samples. According to the results, the seropositivity rates were 10.8% (119/1101) and 15.2% (167/1101) by in house ELISA and IFA, respectively. Among serology coherent samples, the seropositivity rate was 11.1% (116/1047) as detected by both assays after discordant samples (n: 54) were discarded. Of the 1101 stray cats, six (0.54%) were positive by nested PCR while only one of these six samples was positive by ITS1 real time PCR. During PCR, three controls designated as Leishmania infantum, Leishmania tropica, and Leishmania major were used for species identification. According to nested PCR results, L. tropica was identified in two cats (no.76 and 95). In another cat (no. 269), there were two bands in which one of them was well-matched with L. infantum and the other band had ∼850 bp size which does not match with any controls. Remaining three cats (no. 86, 514, and 622) also had the ∼850 bp atypical band size. ITS1 real time PCR detected L. tropica in only one cat (no. 622) which showed an atypical band size in nested PCR. These results indicated that three cats with only one atypical band (no. 86, 514, and 622) and the cat with mixed infection (no. 269) were infected with L. tropica. Altogether, L. tropica was detected in all six DNA positive cats and L. infantum was detected in one cat with mixed infection. In conclusion, although the reservoir role of cats in nature is still unclear the high seroprevalence rate against Leishmania parasites and detecting parasite DNA in stray cats in İzmir indicates that the stray cats are frequently bitten by infected sand flies. Further research activities are required to reveal the frequency of leishmaniasis in cats in different regions of Turkey where Leishmania species are endemic.

Real-time PCR using FRET technology for Old World cutaneous leishmaniasis species differentiation

Background

Recently, there has been a re-emergence of cutaneous leishmaniasis in endemic countries and an increase in imported cases in non-endemic countries by travelers, workers, expatriates, immigrants, and military force personnel. Old World cutaneous leishmaniasis is caused primarily by Leishmania major, L. tropica and L. aethiopica. Despite their low sensitivity, diagnosis traditionally includes microscopic and histopathological examinations, and in vitro cultivation. Several conventional PCR techniques have been developed for species identification, which are time-consuming and labour-intensive. Real-time PCR using SYBR green dye, although provides rapid detection, may generate false positive signals. Therefore, a rapid and easy method such as a FRET-based real-time PCR would improve not only the turn-around time of diagnosing Old World cutaneous Leishmania species but will also increase its specificity and sensitivity.

Methods

A FRET-based real-time PCR assay which amplifies the cathepsin L-like cysteine protease B gene encoding a major Leishmania antigen was developed to differentiate L. major, L. tropica, and L. aethiopica in one single step using one set of primers and probes. Assay performance was tested on cutaneous and visceral strains of Leishmania parasite cultures and isolates of other protozoan parasites as well as human biopsy specimen.

Results

The assay readily differentiates between the three Old World cutaneous leishmaniasis species based on their melting curve characteristics. A single Tm at 55.2 ± 0.5 °C for L. aethiopica strains was distinguished from a single Tm at 57.4 ± 0.2 °C for L. major strains. A double curve with melting peaks at 66.6 ± 0.1 °C and 48.1 ± 0.5 °C or 55.8 ± 0.6 °C was observed for all L. tropica strains. The assay was further tested on biopsy specimens, which showed 100 % agreement with results obtained from isoenzyme electrophoresis and Sanger sequencing.

Conclusion

Currently, there are no published data on real-time PCR using FRET technology to differentiate between Old World cutaneous Leishmania species. In summary, our assay based on specific hybridization addresses the limitations of previous PCR technology and provides a single step, reliable method of species identification and rapid diagnostic applications.

Leishmaniasis in Turkey: first clinical isolation of Leishmania major from 18 autochthonous cases of cutaneous leishmaniasis in four geographical regions

OBJECTIVE

To report isolation of Leishmania major strains obtained from 18 Turkish autochthonous cutaneous leishmaniasis (CL) patients infected with L. major between 2011 and 2014.

METHODS

Initial diagnosis relied on microscopy and culture in enriched medium, prepared by adding specific amounts of liver extract, protein and lipid sources to NNN medium. Promastigotes were then transferred to RPMI medium including 10% of foetal calf serum for mass culture. Species-specific real-time PCR targeting ITS1 region of Leishmania spp. was performed using both lesion aspiration samples and cultured promastigotes. Two of 18 isolates were identified by isoenzyme analysis in the Leishmaniasis Reference Center in Montpellier, France. Each isolate was inoculated into the footpads of six mice to observe the pathogenicity of L. major. Developing lesions were observed, and the thickening of footpads was measured weekly.

RESULTS

Melting curve analyses of 18 isolates showed a peak concordant with L. major, and two of them were confirmed by isoenzyme analyses as L. major zymodeme MON103. In the mouse model, acute lesions seen on day 21 were accepted as an indication of heavy infection. Severe impairments were observed on all mouse footpads over 3 weeks, which even progressed to extremity amputation.

CONCLUSION

Cutaneous leishmaniasis-causing L. major was recently identified in Adana province in southern Turkey, with PCR. Our study shows that such CL cases are not limited to Adana but currently present from western to Southeastern Anatolia, and along the Mediterranean coast. The role of small mammals, the main reservoirs of L. major in Anatolia, needs to be elucidated, as do the underlying factors that cause severe clinical manifestations in L. major infections in Turkey, contrary to the infections in neighbouring countries.

Molecular detection and identification of Leishmania spp. in naturally infected Phlebotomus tobbi and Sergentomyia dentata in a focus of human and canine leishmaniasis in western Turkey

Human visceral leishmaniasis (VL) is reported from 38 provinces of Turkey and dogs are accepted as main reservoir hosts. Kuşadası town, belonging to Aydın province and located in western part of Turkey, is endemic for human and canine visceral leishmaniasis caused by Leishmania infantum MON1 and MON98. In this study, phlebotomine survey was conducted to determine the vector sand fly species and to identify sand fly blood meal sources. In August and September 2012, 1027 sand fly specimens were caught using CDC light traps. Eight Phlebotomus and two Sergentomyia species with the dominancy of Phlebotomus tobbi (61.34%) were detected. A total of 622 female sand flies (571 Phlebotomus; 51 Sergentomyia) were checked for Leishmania infection by direct dissection of the midgut. The half of the midgut content was inoculated into NNN culture for isolation of the parasite. Leishmania species-specific ITS1 real time PCR, conventional PCR assays of ITS1 and hsp70 genes and subsequent sequencing were performed from extracted DNAs. A region of cytochrome b (cyt-b) gene of vertebrates based PCR was used to determine the source of blood meal of sand flies. In microscopical examinations, two female specimens (0.32%) were found naturally infected with high number and different stages of promastigotes. No growth was observed in NNN culture but Leishmania DNA was obtained from both specimens. First positive specimen was identified as P. tobbi and L. infantum DNA was detected. Second specimen was Sergentomyia dentata, but Leishmania DNA could not be identified on species level. A total of 16 blood-fed female P. tobbi specimens were used for blood meal analysis and eight, three and one specimens were positive for human, dog and mouse, respectively. This is the first detection of Leishmania promastigotes using microscopical examination in P. tobbi and S. dentata in human and canine visceral leishmaniasis endemic area in western part of Turkey. Our results indicate that, (i) P. tobbi is the principal vector species and (ii) human and dogs are main blood sources. The detection of Leishmania sp. in Sergentomyia species may be an evidence for natural cycle of Sauro-leishmania agents in the area.

Evaluation of conjunctival swab sampling in the diagnosis of canine leishmaniasis: A two-year follow-up study in Çukurova Plain, Turkey

The diagnosis of canine leishmaniasis (CanL) in symptomatic and asymptomatic dogs is a very important and problematic public health issue in Turkey. A longitudinal study was carried out on dogs in selected villages in the Çukurova Plain in Turkey, from July 2011 to June 2013, where cutaneous (CL) and visceral (VL) leishmaniasis is endemic. The study aimed to determine the prevalence of CanL and to evaluate the early diagnostic performance of the non-invasive conjunctival swab nested PCR (CS n-PCR) test in comparison with the Indirect Fluorescent Antibody Test (IFAT). The consecutive blood and CS samples from a representative number of dogs (80-100 dogs/each survey) were collected in a cohort of 6 villages located in the area. Clinical symptoms, demographic and physical features about each dog were noted and lymph node aspiration samples were obtained from selected dogs with lymphadenopathy. In four surveys during the period, a total of 338 sets (blood and CS) of samples from 206 dogs were obtained, such that 83 dogs were sampled more than once. In the cross-sectional analysis, the CanL prevalence was found to be 27.18% (between 7.14% and 39.13%) by IFAT and 41.74% (between 29.03% and 46.66%) by CS n-PCR. The isolated strains were identified as Leishmania infantum MON-1 (n=9) and MON-98 (n=2) by MLEE analysis. Genetic studies targeting the Hsp70 and ITS1 regions performed on 11 dog isolates also showed two clear separate groups. According to IFAT results, 24 of the 83 dogs sampled more than once showed seroconversion (n=19) or a four-fold increase in Ab titers (n=5), while 17 were positive in the initial screening. Forty-two dogs stayed negative during the whole period. The natural Leishmania exposure rate was detected as 31.14% in the study area. CS n-PCR only detected Leishmania infection earlier than IFAT in 8 dogs. No statistical difference was found after the analysis of demographical and physical data. The results indicated that (i) circulation of the dog population is very common in settlements in the Çukurova Plain, but the disease prevalence is high and stable, (ii) the performance of CS n-PCR for detecting Leishmania-dog contact is higher than IFAT, (iii) and some of the parasites isolated from dogs have different zymodemes and/or genotypes from previous human and sand fly isolates; suggesting the probability of two different cycles of leishmaniasis in this particular area. This hypothesis should be supported by future studies targeting vectors and reservoirs.

Natural Leishmania infection of Phlebotomus sergenti (Diptera: Phlebotominae) in an endemic focus of cutaneous leishmaniasis in Şanlıurfa, Turkey

Sand flies (Diptera: Phlebotominae) were surveyed for Leishmania in various villages of Şanlıurfa in southeast Turkey. A total of 474 sand flies were collected by CDC light traps. Phlebotomus sergenti Parrot (49.6%) and Phlebotomus papatasi (Scopoli) (48.1%) were the most abundant species, followed by Phlebotomus alexandri Sinton (1.05%), Phlebotomus perfiliewi Parrot (0.4%), Phlebotomus (Adlerius) sp. (0.2%) and Sergentomyia theodori Parrot (0.4%). 196 female sand flies were grouped in 34 pools of max 10 specimens each and 4 pools of P. sergenti were found positive for Leishmania DNA, detected by using ITS-1 primer set. This is the first molecular detection and identification of Leishmania tropica within naturally infected P. sergenti from the most important focus of anthroponotic cutaneous leishmaniasis in Turkey. The high frequency of P. sergenti together with natural infection by the parasite makes this species the probable vector of L. tropica in Şanlıurfa. The data obtained from this study could be used in strategic planning for the control of leishmaniasis in the region.

A Comparison of Demographic and Clinical Characteristics of Syrian and Turkish Patients with Cutaneous Leishmaniasis

Cutaneous leishmaniasis (CL) is a significant public health problem with increasing incidence, especially in extreme circumstances. In this study, we compared the sociodemographic and clinical characteristics of 685 Syrian CL patients afflicted by the Syrian conflict and 685 Turkish CL patients in 2012. Patient age, gender, duration of disease, lesion size, type, and localization were evaluated. The duration of CL disease in Syrian CL patients (4.5 ± 4.3 weeks) was shorter than that of Turkish CL patients (11.9 ± 9.7 weeks). The number of lesions was greater in Syrian patients (2.46 ± 2.43) than in Turkish patients (1.93 ± 1.47). Lesion sizes were comparable between both groups (Syrian, 11.2 ± 8.7 mm; Turkish, 10.7 ± 7.7 mm). In Syrian CL patients, nodular type lesions were the most common (325 patients, 49.1%), whereas, in Turkish CL patients, ulcer type lesions were the most common (352 patients, 51.5%). Our results indicate variations in the clinicoepidemiological features of CL between Turkish and Syrian patients within Sanliurfa province. This highlights the impact of social unrest and environmental conditions on the epidemiology of CL within this region. Approaches to prevention, control, and treatment of CL in these areas should take into consideration the emerging changes in clinicoepidemiological parameters of the disease.

Trypanosomatids topoisomerase re-visited. New structural findings and role in drug discovery

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There is an urgent need of new treatments against trypanosomatids-borne diseases.

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DNA topoisomerases are pointed as potential drug targets against unicellular parasites.

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Trypanosomatids have a full set of DNA topoisomerases in both nucleus and kinetoplast.

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TopII and TopIII are located in the kinetoplast and fully involved in kDNA replication.

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Tritryps TopIB differ in structure from mammalian’s pointing to an attractive target.

The Trypanosomatidae family, composed of unicellular parasites, causes severe vector-borne diseases that afflict human populations worldwide. Chagas disease, sleeping sickness, as well as different sorts of leishmaniases are amongst the most important infectious diseases produced by Trypanosoma cruzi, Trypanosoma brucei and Leishmania spp., respectively. All these infections are closely related to weak health care services in low-income populations of less developed and least economically developed countries. Search for new therapeutic targets in order to hit these pathogens is of paramount priority, as no effective vaccine is currently in use against any of these parasites. Furthermore, present-day chemotherapy comprises old-fashioned drugs full of important side effects. Besides, they are prone to produce tolerance and resistance as a consequence of their continuous use for decades. DNA topoisomerases (Top) are ubiquitous enzymes responsible for solving the torsional tensions caused during replication and transcription processes, as well as in maintaining genomic stability during DNA recombination. As the inhibition of these enzymes produces cell arrest and triggers cell death, Top inhibitors are among the most effective and most widely used drugs in both cancer and antibacterial therapies. Top relaxation and decatenation activities, which are based on a common nicking–closing cycle involving one or both DNA strands, have been pointed as a promising drug target. Specific inhibitors that bind to the interface of DNA-Top complexes can stabilize Top-mediated transient DNA breaks. In addition, important structural differences have been found between Tops from the Trypanosomatidae family members and Tops from the host. Such dissimilarities make these proteins very interesting for drug design and molecular intervention. The present review is a critical update of the last findings regarding trypanosomatid’s Tops, their new structural features, their involvement both in the physiology and virulence of these parasites, as well as their use as promising targets for drug discovery.