Guideline sources The following summarized guidelines for the evaluation and management of visceral leishmaniasis are prepared by our editorial team based on guidelines from the Infectious Diseases Society of America (IDSA/ASTMH 2017). 1 Guidelines 1. Diagnostic investigations Laboratory testing: Use multiple diagnostic approaches to maximize the likelihood of a positive Leishmania result, using methods such as: visualization of the characteristic amastigote in smears or tissue (histopathology) parasite isolation by culture molecular detection of parasite deoxyRNA serologic testing. B Show 6 more Skin testing: do not obtain Leishmania skin testing for any form of leishmaniasis. Recognize that there are no standardized, approved, or commercially available skin-test products in North America. D https://web.pathway.md/diseases/recySfu05uqH58CEd 1/3 6/29/23, 3:43 AM Visceral leishmaniasis Pathway 2. Diagnostic procedures Biopsy: Collect tissue aspirates or biopsy specimens for smears, histopathology, parasite culture, and molecular testing. B Perform bone marrow aspiration as the preferred first source of a diagnostic sample. Consider using liver, enlarged lymph nodes, and whole blood (buffy coat) as other potential sources of tissue specimens. B 3. Medical management Indications for treatment: treat patients with clinical abnormalities compatible with visceral leishmaniasis and laboratory evidence of visceral leishmaniasis. B Show 2 more Amphotericin B: Administer liposomal amphotericin B in immunocompetent patients with visceral leishmaniasis, with a dose regimen of 3 mg/kg/day IV on days 1-5, 14, and 21 (total dose, 21 mg/kg). A Do not switch to amphotericin B deoxycholate in patients with contraindications to, or substantial toxicity with, liposomal amphotericin B, with the exception of patients developing liposome-induced complement activation-related pseudoallergy. Consider using amphotericin B lipid complex in this situation. D Miltefosine: administer oral miltefosine 2.5 mg/kg/day (maximum, 150 mg, divided in 3 doses) for 28 days as an alternative to liposomal amphotericin B in immunocompetent patients with visceral leishmaniasis caused by Leishmania donovani, acquired in the Indian subcontinent (South Asia), who are 12 years old, weighs 30 kg (particularly those < 75 kg), and is not pregnant or breastfeeding. B Pentavalent antimony: administer pentavalent antimony (20 mg SbV/kg/day IV or IM for 28 days) in immunocompetent persons with visceral leishmaniasis acquired in areas where the prevalence of antimony-resistant Leishmania species is low (< 10%). A 4. Specific circumstances Patients with human immunodeficiency virus/acquired immunodeficiency syndrome: offer liposomal amphotericin B for the treatment of visceral leishmaniasis in immunocompromised patients in North America. B Show 5 more Patients with other causes of immunosuppression: offer liposomal amphotericin B as the drug of choice for immunosuppressed patients with visceral leishmaniasis. B Show 6 more 5. Follow-up and surveillance https://web.pathway.md/diseases/recySfu05uqH58CEd 2/3 6/29/23, 3:43 AM Visceral leishmaniasis Pathway Monitoring of treatment response: Use clinical parameters to monitor the response to treatment, as they correlate well with parasitologic responses to treatment for visceral leishmaniasis. B Do not obtain parasitologic confirmation of response, such as by repeat bone marrow aspiration for microscopy and culture after treatment, in patients showing timely clinical response. Be aware that antibody levels fall but over many months or longer. D Management of treatment failure: administer an alternative drug or a higher dose or a longer course of liposomal amphotericin B in immunocompetent patients with visceral leishmaniasis not responding to therapy with liposomal amphotericin B. B Show 2 more Management of relapse: administer an alternative drug or another, potentially longer, course of therapy with the initial drug immunocompetent patients with visceral leishmaniasis responding to initial therapy but subsequently experiencing a relapse. Consider using a higher dose of liposomal amphotericin B if it was the drug used for initial therapy. B Clinical findings Symptoms Vital signs Cough body temperature Night sweats Integument exam Weight loss Alopecia Abdominal exam Skin scaling Hepatomegaly Splenomegaly Hematological findings Anemia Coagulopathy Monocytosis blood leukocyte count blood platelet count References 1. Naomi Aronson, Barbara L Herwaldt, Michael Libman et al. Diagnosis and Treatment of Leishmaniasis: Clinical Practice Guidelines by the Infectious Diseases Society of America IDSA and the American Society of Tropical Medicine and Hygiene ASTMH . Am J Trop Med Hyg. 2017 Jan 11; 96 1 24 45. Open https://web.pathway.md/diseases/recySfu05uqH58CEd 3/3