Leishmania infantum and human visceral leishmaniasis, Argentina.
Article Type: Letter to the editor
Subject: Kala-azar (Causes of)
Kala-azar (Research)
Kala-azar (Diagnosis)
Authors: Barrio, Alejandra
Parodi, Cecilia M.
Locatelli, Fabricio
Mora, Maria C.
Basombrio, Miguel A.
Korenaga, Masataka
Hashiguchi, Yoshihisa
Bustos, Maria F. Garcia
Gentile, Alberto
Marco, Jorge D.
Pub Date: 02/01/2012
Publication: Name: Emerging Infectious Diseases Publisher: U.S. National Center for Infectious Diseases Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 U.S. National Center for Infectious Diseases ISSN: 1080-6040
Issue: Date: Feb, 2012 Source Volume: 18 Source Issue: 2
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: Argentina Geographic Code: 3ARGE Argentina
Accession Number: 281175431
Full Text: To the Editor: In Argentina, 14 autochthonous human cases of visceral leishmaniasis (VL) were reported during 1925-1989. These cases occurred in different localities in Salta, Jujuy, Santiago del Estero, and Chaco Provinces of northwestern Argentina (online Appendix Figure, wwwnc.cdc.gov/EID/article/18/2/110924-FA1.htm), where cutaneous leishmaniasis (CL) caused principally by Leishmania (Viannia) braziliensis is endemic.

It had been postulated that scattered/sporadic VL cases could be caused by visceralization of dermatrophic Leishmania spp. because of 1) absence of already recognized L. (Leishmania) infantum vector species; 2) geographic overlap with the region where CL is endemic; 3) simultaneous symptoms of CL; or 4) lack of detailed parasitic characterization at the molecular level for cases of suspected VL (1). However, during recent decades, urban outbreaks of VL have spread to southern regions of South America (Mato Grosso do Sul, Brazil, and Asuncion, Paraguay) near the northern border with Argentina.

In May 2006, an autochthonous human case of VL was reported in Posadas (northeastern Argentina); it was associated with the canine visceral form of the disease. In addition, the presence of Lutzomyia longipalpis sandflies was also reported (2). Currently, 58 human VL cases have been reported in Posadas (3), and >7,000 infected dogs, Lu. longipalpis sandflies, and canine VL have been found 350 km south of Posadas (4).

During 2007-2008, new VL cases in 4 children and 7 dogs were reported clustering in time and space in La Banda-Santiago del Estero in the dry Chaco region of Argentina. This focus showed a different pattern from that found in the only urban outbreak of VL reported (nearly the same number of cases in humans and dogs, and the suspected vector was Lu. migonei sandflies instead of Lu. longipalpis sandflies) (5).

We report a case of autochthonous human VL in Salta Argentina that was caused by L. (L.) infantum. This parasite was characterized by cytochrome b (cytb) gene sequencing. Sequencing of this gene has been validated for precise characterization of Leishmania spp. (6,7).

On September 9, 2009, a 44-year-old man from Salta, Argentina (online Appendix Figure), was admitted to the Infectious Disease Service at Hospital Senor del Milagro in Salta. The patient had fever, weight loss, dyspepsia, and splenomegaly that evolved over 3 weeks. Physical examination showed cutaneous and mucosal paleness. His general condition was feverish and rapidly deteriorating.

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Laboratory tests at the time of final diagnosis showed anemia, leukocytopenia, thrombocytopenia, and increased levels of lactate dehydrogenase. Results of urinalysis and coproculture were negative for parasites. Electrophoresis of serum proteins showed increased levels of gamma globulins. The differential diagnosis was negative for malaria, mycosis, autoimmune hepatitis, and lymphoma. A bone marrow smear showed abundant amastigotes by Giemsa staining (Figure, panel A). The patient was treated with liposomal amphotericin B, 3 mg/day for 7 days, and recovered (8).

After a comprehensive interview, we verified that this patient had not been in the VL-endemic area in Argentina. However, he had worked (deforestation activities) during January-February 2009 on a farm in Finca Las Maravillas (22[degrees]3'29.30"S, 63[degrees]14'28.17"W), where he had been bitten by phlebotomines and acquired the disease. This farm was situated in the dry Chaco region near the border with Bolivia and Paraguay (zones with VL) (9), a region with intensive deforestation and agricultural activities.

For species identification, DNA was extracted from a bone marrow aspirate and peripheral blood. We amplified by nested PCR and sequenced the cytb gene (Figure, panel B) (6). The aligned 817-bp sequence obtained showed 100% homology with the cytb gene of the MHOM/ TN/80/IPT1 L. (L.) infantum World Health Organization reference strain (Tunisian strain) and 99.3% homology with the MHOM/BR/74/PP75 L. (L.) chagasi strain (Brazilian strain) (7).

L. (L.) infantum was identified as the causative agent of this VL case in Salta, Argentina, where VL cases had not been seen for 50 years. Our findings indicate that this case was not caused by visceralization or a dermatropic Leishmania spp. We suggest that the scattered pattern of VL incidence in the dry Chaco region is caused by an enzootic cycle with accidental human transmission (5).

There are no reports of Lu. longipalpis sandflies in the study area or surrounding areas (10). Nevertheless, studies on natural infections of vector sandflies and reservoir-host animals (especially dogs) are needed. Therefore, the search for naturally infected sandflies and reservoirs of this infection should be intensified. Epidemiologic surveys of dogs are needed to identify spread of VL foci in areas of deforestation. Deforestation could alter vector and reservoir range and parasite density in the enzootic cycle and increase human exposure to infected vectors.

Acknowledgments

We thank Servicio de Enfermedades Infecciosas-Hospital Senor del Milagro, Salta, Argentina, and Noemi Davalo for support during the clinical phase of the study; Jesus Sajama for drawing the map; and Ruben Cardozo for conducting field research.

This study was supported in part by the El Consejo de Investigacion de la Universidad Nacional de Salta and Comision Nacional Salud InvestigaMinisterio de Salud de la Nacion, Argentina.

Alejandra Barrio, Cecilia M. Parodi, Fabricio Locatelli, Maria C. Mora, Miguel A. Basombrio, Masataka Korenaga, Yoshihisa Hashiguchi, Maria F. Garcia Bustos, Alberto Gentile, and Jorge D. Marco

Author affiliations: Universidad Nacional de Salta, Salta, Argentina (A. Barrio, C.M. Parodi, M.C. Mora, M.A. Basombrio, M.F. Garcia Bustos, J.D. Marco); Kochi Medical School, Kochi, Japan (F. Locatelli, M. Korenaga, Y. Hashiguchi); and Ministerio de Salud Publica-Provincia de Salta, Salta (A. Gentile)

DOI: http://dx.doi.org/10.3201/eid1802.110924

References

(1.) Martin-Sanchez J, Navarro-Mari JM, Pasquau-Liano J, Salomon OD, Morillas-Marquez F. Case report. Visceral leishmaniasis caused by Leishmania infantum in a Spanish patient in Argentina: what is the origin of the infection? BMC Infect Dis. 2004;4:20. http://dx.doi. org/10.1186/1471-2334-4-20

(2.) Salomon O, Sinagra A, Nevot M, Barberian G, Paulin P, Estevez J, et al. First visceral leishmaniasis focus in Argentina. Mem Inst Oswaldo Cruz. 2008;103:10911. http://dx.doi.org/10.1590/S0074 02762008000100018

(3.) Cruz I, Acosta L, Gutierrez MN, Nieto J, Canavate C, Deschutter J, et al. A canine leishmaniasis pilot survey in an emerging focus of visceral leishmaniasis: Posadas (Misiones, Argentina). BMC Infect Dis. 2010;10:342. http://dx.doi. org/10.1186/1471-2334-10-342

(4.) Fernandez MS, Salomon OD, Cavia R, Perez AA, Acardi SA, Guccione JD. Lutzomyia longipalpis spatial distribution and association with environmental variables in an urban focus of visceral leishmaniasis, Misiones, Argentina. Acta Trop. 2010;114:81-7. http://dx.doi. org/10.1016/j.actatropica.2010.01.008

(5.) Salomon OD, Quintana MG, Bezzic G, Moranc ML, Betbederc E, Valdez DV. Short communication: Lutzomyia migonei as putative vector of visceral leishmaniasis in La Banda, Argentina. Acta Trop. 2010;113:84-7. http://dx.doi. org/10.1016/j.actatropica.2009.08.024

(6.) Myint CK, Asato Y, Yamamoto Y, Kato H, Bhutto AM, Soomro FR, et al. Polymorphisms of cytochrome b gene in Leishmania parasites and their relation to types of cutaneous leishmaniasis lesions in Pakistan. J Dermatol. 2008;35:7685. http://dx.doi.org/10.1111/j.13468138.2008.00419.x

(7.) Foulet F, Botterel F, Buffet F, Morizot G, Rivollet D, Deniau M, et al. Detection and identification of Leishmania species from clinical specimens by using a real-time PCR assay and sequencing of the cytochrome b gene. J Clin Mi crobiol. 2007;45:2110-5. http://dx.doi. org/10.1128/JCM.02555-06

(8.) Rosenthal E, Delaunay P, Jeandel PY, Haas H, Pomares-Estran C, Marty P. Liposomal amphotericin B as treatment for visceral leishmaniasis in Europe, 2009. Med Mal Infect. 2009;39:741-4. http://dx.doi. org/10.1016/j.medmal.2009.05.001

(9.) Bastrenta B, Mita N, Buitrago R, Vargas F, Flores M, Machane M, et al. Human mixed infections of Leishmania spp. and Leishmania-Trypanosoma cruzi in a sub-Andean Bolivian area: identification by polymerase chain reaction/hybridization and isoenzyme. Mem Inst Oswaldo Cruz. 2003;98:255-64. http://dx.doi. org/10.1590/S0074-02762003000200015

(10.) Salomon OD, Rosa JR, Stein M, Quintana MG, Fernandez MS, Visintin AM, et al. Phlebotominae (Diptera: Psycodidae) fauna in the Chaco region and cutaneous leishmaniasis transmission patterns in Argentina. Mem Inst Oswaldo Cruz. 2008;103:578-84. http://dx.doi. org/10.1590/S0074-02762008000600011

Address for correspondence: Alejandra Barrio, Catedra de Microbiologia y Parasitologia, Facultad de Ciencias de la Salud, Universidad Nacional de Salta, Avenida Bolivia 5150, CP 4400 Salta, Argentina; email: aleba05@yahoo. com.ar
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