Leishmaniasis in Transplant Candidates and Recipients: Diagnosis and Management

Abstract

Leishmaniasis is a rare disease in both solid-organ and hematopoietic stem cell transplantation. Additionally, the frequency of disease is likely related to the leishmaniasis prevalence in the general population. Although cutaneous leishmaniasis (CL) presentation is more prevalent than that of visceral leishmaniasis (VL) in the general population, the opposite occurs in transplant patients. The current available knowledge is based on small series, case reports, or extrapolations from studies conducted in the general population or in immunocompromised subjects. Therefore, recommendations for disease management are based on the opinion of experts. Leishmania transmission through organ grafts has not been conclusively demonstrated, and there are relatively low rates of transfusion-transmitted leishmaniasis (TTL). To date, compulsory screening for VL in organ donors and the deferral criteria have still not been established. In the context of transplant recipients, diagnosis and management remain a challenge. Delayed diagnosis frequently occurs because of low clinical suspicion and atypical disease presentation. Liposomal amphotericin is the drug of choice and the most commonly used therapy. However, patient profile, Leishmania species, disease extent, drug availability or toxicity, presence of concomitant infections, and especially response can influence this choice. Immunosuppression dose reduction is often recommended, but such decisions must be taken on an individual basis. The main challenges include donor screening and organ deferral, duration of therapy, secondary prophylaxis, and follow-up.

Parasitic infections in hematopoietic stem cell transplant recipients

“…There are three major clinical manifestations of the disease, cutaneous, mucocutaneous, and visceral with the cutaneous being the most common form. 119 Interestingly, in transplant patients, the more severe visceral form was seen more commonly, possibly due to the immunocompromised state of the patients. Manifestations of visceral disease include the classic triad of fever, hepatosplenomegaly, and pancytopenia.…”

“…122 Serology testing using ELISA can also be used but in HSCT recipients, they should be interpreted carefully due to their impairment in antibody production. 67,119 Liposomal amphotericin B is the treatment of choice for visceral leishmaniasis, with a reported 95% cure rate in immunocompetent individuals and 84% cure rate in SOT patients. 26 In HSCT patients, most reported cases had successful outcomes after treatment with liposomal amphotericin B.…”

“…Other diagnostic methods include PCR, which not only offers higher sensitivity amongst immunocompromised individuals but is also a non‐invasive way of diagnosing the disease, making it the recommended method of diagnosis in HSCT patients 122 . Serology testing using ELISA can also be used but in HSCT recipients, they should be interpreted carefully due to their impairment in antibody production 67,119 …”