Confirm presence of the disease. Screen blood donors. Dog with clinical signs and/or clinicopathological abnormalities compatible with CanL

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1 CANINE LEISHMANIOSIS (CanL) LeishVet brief information for the practicing veterinarian

2 LEISHVET GUIDELINES FOR THE PRACTICAL MANAGEMENT OF CANINE LEISHMANIOSIS (CanL) Content DIAGNOSIS 3 CLINICAL STAGING 6 THERAPY 9 Monitoring 10 PREVENTION 12 REFERENCES 13 ABOUT LEISHVET 14 LEISHVET MEMBERS 14

3 DIAGNOSIS DIAGNOSIS Diagnosis is performed based on physical and clinicopathological manifestations and by confirmation of infection, using mainly serological and molecular techniques. Main purposes for the diagnosis of Leishmania infantum infection: A Confirm presence of the disease. B Screen clinically healthy dogs living in or travelling to endemic areas. C Screen blood donors. Diagnostic Approach Dog with clinical signs and/or clinicopathological abnormalities compatible with CanL HIGH Confirmed CanL POSITIVE Quantitative serology LOW Cytological/histological evaluation YES Leishmania amastigotes POSITIVE NO PCR NEGATIVE High suspicion of CanL NEGATIVE Consider other diagnoses 3

LEISHVET GUIDELINES FOR THE PRACTICAL MANAGEMENT OF CANINE LEISHMANIOSIS (CanL) Clinical manifestations and laboratory abnormalities found Clinical manifestations Laboratory abnormalities General

4 LEISHVET GUIDELINES FOR THE PRACTICAL MANAGEMENT OF CANINE LEISHMANIOSIS (CanL) Clinical manifestations and laboratory abnormalities found Clinical manifestations Laboratory abnormalities General Serum proteins and electrophoretogram Generalized lymphadenomegaly Loss of body weight Decreased or increased appetite Lethargy Pallor mucous membranes Splenomegaly Polyuria and polydypsia Fever Vomiting Diarrhea (including chronic colitis) Hyperglobulinemia ( Polyclonal beta- and/or gammaglobulinemia) Hypoalbuminemia Decreased albumin/globulin ratio Cutaneous CBC/Hemostasis Non-pruritic exfoliative dermatitis with or without alopecia Erosive-ulcerative dermatitis Nodular dermatitis Papular dermatitis Pustular dermatitis Onychogryphosis M ild to moderate non-regenerative anemia Leukocytosis or leukopenia Thrombocytopathy Thrombocytopenia Impaired secondary hemostasis and fibrinolysis Ocular Biochemical profile/urinalysis Blepharitis (exfoliative, ulcerative, or nodular) and conjunctivitis (nodular) K eratoconjunctivitis (either common or sicca) Anterior uveitis/endophthalmitis Mild to severe proteinuria Renal azotemia Elevated liver enzyme activities Other M ucocutaneous and mucosal ulcerative or nodular lesions (oral, genital, and nasal) Epistaxis Lameness (erosive or non-erosive poly arthritis, osteomyelitis, polymyositis) Atrophic masticatory myositis Vascular disorders (systemic vasculitis, arterial thromboembolism) Neurological disorders Sand fly (Phlebotomus spp.) feeding on a human finger 4 ( Photo by R. Pospischil, Monheim, Germany)

5 DIAGNOSIS in CanL due to infection with L. infantum Infected but healthy versus sick dogs Dogs with clinical leishmaniosis are those presenting suggestive clinical signs and/or clinicopatho A logical abnormalities, and having a confirmed L. infantum infection. Dogs with subclinical infection (or clinically healthy but infected dogs) are those that present neither B clinical signs on physical examination nor clinicopathological abnormalities on routine laboratory tests (CBC, biochemical profile and urinalysis) but have a confirmed L. infantum infection. Diagnostic methods A B C Parasitological: cytology/histology, immunohistochemistry and culture. Molecular: conventional, nested and real-time polymerase chain reaction (PCR). Serological: quantitative (IFAT and ELISA) and qualitative (rapid tests). samples and techniques to be used for PCR A Samples recommended (more sensitive tissues): bone marrow lymph node spleen skin conjunctiva B Samples not recommended (less sensitive samples): blood, buffy coat, and urine. More sensitive technique: real-time PCR. C Intracellular Leishmania infantum amastigotes within a dog s macrophage (bone marrow cytology; Giemsa-stained blood smear)( A. F. Koutinas, Thessaloniki, Greece) 5

6 LEISHVET GUIDELINES FOR THE PRACTICAL MANAGEMENT OF CANINE LEISHMANIOSIS (CanL) CLINICAL STAGING A system that divides the disease into four stages and is aimed at assisting the clinician in determining the appropriate therapy, forecasting prognosis, and implementing follow-up steps required for the management of the canine leishmaniosis patient. Clinical staging of CanL based on serological status, clinical signs, laboratory findings, and type of therapy and prognosis for each stage Clinical stages Serology* Clinical signs Stage I Negative to low positive antibody levels Mild peripheral lymphadenomegaly papular dermatitis Low to high positive antibody levels Stage I signs plus: diffuse or symmetrical cutaneous lesions such as exfoliative dermatitis/onychogryphosis, ulcerations (planum nasale, footpads, bony prominences, mucocutaneous junctions), anorexia, weight loss, fever, and epistaxis Medium to high positive antibody levels Dogs which apart from the signs listed in stages I and II may present signs originating from immune-complex lesions: vasculitis, arthritis, uveitis, and glomerulonephritis Medium to high positive antibody levels Dogs with clinical signs listed in stage III: pulmonary thromboembolism, or nephrotic syndrome and end-stage renal disease Mild disease Stage II Moderate disease Stage III Severe disease Stage IV Very severe disease * Dogs with negative to medium positive antibody levels should be confirmed as infected by other diagnostic techniques such as cytology, histology, immunohistochemistry, or PCR. High levels of antibodies defined as a three- to fourfold elevation above the cut off level of a well-established refer ence laboratory are conclusive of a diagnosis of CanL. 6

7 CLINICAL STAGING Sand fly (Phlebotomus spp.) Laboratory findings Therapy Prognosis Usually no clinicopathological abnormalities observed Good Normal renal profile: creatinine < 1.4 mg/dl; nonprotein uric: UPC < 0.5 Treat with anti-leishmania short-term therapy or monitor without treatment** Clinicopathological abnormalities such as mild non-regenerative anemia, hyperglobulinemia, hypo albuminemia, serum hyperviscosity syndrome Allopurinol + meglumine antimoniate or allopurinol + miltefosine Good to guarded Allopurinol + meglumine antimoniate or allopurinol + miltefosine Guarded to poor Substage a) Normal renal profile: creatinine < 1.4 mg/dl; non-proteinuric: UPC < 0.5 b) Creatinine < 1.4 mg/dl; UPC = Clinicopathological abnormalities listed in stage II: Chronic kidney disease (CKD) IRIS stage I with UPC > 1 or stage II (creatinine mg/dl) Follow IRIS1 guidelines for CKD Clinicopathological abnormalities listed in stage II: Allopurinol (alone) CKD IRIS stage III (creatinine 2 5 mg/dl) and stage IV (creatinine > 5 mg/dl) Follow IRIS guidelines for CKD Poor Nephrotic syndrome: marked proteinuria UPC > 5 1 IRIS: International Renal Interest Society ( ** Initiation of any therapeutic intervention is dependent on the individual case. Dogs in stage I are likely to require less prolonged treatment with one or two combined drugs or alternatively monitoring with no treatment. However, there is limited information on dogs in this stage and, therefore, treatment options remain to be defined. 7

LEISHVET GUIDELINES FOR THE PRACTICAL MANAGEMENT OF CANINE LEISHMANIOSIS (CanL) Some clinical signs found in CanL A B C D E 8 Epistaxis Bilateral uveitis and corneal

8 LEISHVET GUIDELINES FOR THE PRACTICAL MANAGEMENT OF CANINE LEISHMANIOSIS (CanL) Some clinical signs found in CanL A B C D E 8 Epistaxis Bilateral uveitis and corneal opacity Purulent conjunctivitis and blepharitis Exfoliative alopecia in the rear leg and popliteal lymphadenomegaly Marked cachexia and generalized exfoliative alopecia

THERAPY Drugs Dosages Main side effects Meglumine antimoniate* 75 100 mg/kg once a day or 40 75 mg/kg twice a day for 4 weeks S.C.

9 THERAPY Drugs Dosages Main side effects Meglumine antimoniate* mg/kg once a day or mg/kg twice a day for 4 weeks S.C.** Potential nephrotoxicity C utaneous abscesses/ cellulitis Miltefosine* 2 mg/kg once a day for 28 days P. O. Vomiting Diarrhea Allopurinol 10 mg/kg twice a day for at least 6 12 months P. O. Xanthine urolithiasis THERAPY Current treatment protocols for CanL P. O.: per os; S.C.: subcutaneous * Registered for veterinary use in some European countries; both drugs are commonly recommended in combination with allopurinol. ** Recommended dosages out of label but according to pharmacokinetic and clinical studies in dogs. Treatment prolongation by 2 3 weeks may be considered if patient improvement is insufficient. Disclaimer: Information given here on drugs and dosages are based on a consensus of clinical and scientific experience by the LeishVet members. These recommendations have been published in scientific peer-reviewed journals. Veterinary practitioners are requested to check with product leaflets and product registrations in their related country prior to any product selection and initiation of treatment. 9

LEISHVET GUIDELINES FOR THE PRACTICAL MANAGEMENT OF CANINE LEISHMANIOSIS (CanL) Monitoring Recommended monitoring of clinicopathological parameters and serology during and after treatment of CanL

10 LEISHVET GUIDELINES FOR THE PRACTICAL MANAGEMENT OF CANINE LEISHMANIOSIS (CanL) Monitoring Recommended monitoring of clinicopathological parameters and serology during and after treatment of CanL Parameter Frequency Clinical and laboratory: Anamnesis (clinical history) Complete physical examination CBC Biochemical profiles Serum electrophoresis (optional) Urinalysis (incl. UPC in case of a proteinuric patient) After the 1st month of treatment Every 3 4 months during the 1st year After clinical recovery: 6-monthly recheck Serology*: First testing 6 months after onset of treatment Every 6 months or at least once a year Real-time PCR Current scientific status: not recommended unless combined with serology * Possible serological findings following therapy: Some dogs present a significant decrease in antibody levels (more than a twofold dilutions difference between the first and the following samples) associated with clinical improvement within 6 months to 1 year of treatment. Other dogs might not have a decrease in antibody levels despite clinical improvement. In contrast, a marked increase of antibody levels (more than two-fold elevation between monitoring samples) should be interpreted as a marker of relapse, especially in dogs following the dis continuation of treatment. 10

Management of Leishmania-seropositive but clinically healthy dogs and PCR-positive but seronegative dogs Management of dogs with no clinical signs and laboratory abnormalities Seropositive

11 Management of Leishmania-seropositive but clinically healthy dogs and PCR-positive but seronegative dogs Management of dogs with no clinical signs and laboratory abnormalities Seropositive SeroNegative What to do Monitor every 3 6 months. Evaluate seroconversion. Evaluate possible development of illness. Monitoring Retest to confirm seropositivity. Monitor with physical examination, routine laboratory tests, and serological tests every 3 6 months. Treatment not recommended Prevention Protect with topical insecticide repellents to minimize the transmission of L. infantum. A It is recommended to use serology alone or the combination of serology with PCR for screening healthy dogs and to avoid screening clinically healthy dogs only by PCR. B Confirmed seropositive dogs should be monitored periodically with physical examinations, routine laboratory, and serological tests on a regular basis every 3 6 months to assess the possible progression of infection towards disease. 11

LEISHVET GUIDELINES FOR THE PRACTICAL MANAGEMENT OF CANINE LEISHMANIOSIS (CanL) PREVENTION Effective prevention of sand fly bites can be achieved when the following steps are taken: (i) keeping the

12 LEISHVET GUIDELINES FOR THE PRACTICAL MANAGEMENT OF CANINE LEISHMANIOSIS (CanL) PREVENTION Effective prevention of sand fly bites can be achieved when the following steps are taken: (i) keeping the dog indoors during the sand fly season from dusk to dawn; (ii) reducing the microhabitats favorable to sand flies in the vicinity of the house or in locations where the dog spends time; (iii) usage of environmental insecticide treatment, and (iv) usage of topical insecticides with proven activity against the sand flies which bite dogs. In recent years, various insecticide formulations have been evaluated under laboratory and field conditions with encouraging results. Field studies have shown that some topical insecticides used in canine populations have been effective in reducing the transmission of infection in both dogs and humans. Veterinarians and dog owners are advised to check the label recommendations of products and follow the manufacturer s instructions, especially for the correct application of the product and frequency of reapplication. Client education on the maintainance of appropriate insecticide throughout the period of sand fly activity is also crucial for the protection of dogs. Preventive measures in dogs from non-endemic areas travelling to endemic areas should be the same as for healthy or sick dogs that live in endemic areas. As recommended for dogs living in the endemic areas, advice should be given for follow-up visits after returning for clinical and laboratory checkup. Prevention should be an integrated approach including vaccination against L. infantum with an effective vaccine and the application of a topically applied insecticide with repellent properties throughout the period of sand fly activity. Topical insecticides applied to dogs living in or travelling to endemic areas to be maintained during the entire period of potential exposure to/or activity of sand flies: A ermethrin/imidacloprid, as a spot-on formulation. Treatment provides repellent (anti-feeding) P activity against sand flies (Phlebotomus perniciosus) for three weeks. It is recommended to repeat administra tion every 3 weeks in dogs living outdoors. It should be applied at least 2 days before travelling or before exposure. Deltamethrin-impregnated collars. Control of feeding by phlebotomine sand flies (P. perniciosus) for B a period of 5 6 months. Replace collar every 5 6 months. It should be applied at least 1 2 weeks before travelling or before exposure. 12

REFERENCES Baneth G, Koutinas AF, Solano-Gallego L, Bourdeau P, Ferrer L: Canine leishmaniosis new concepts and insights on an expanding zoonosis: part one.

13 REFERENCES Baneth G, Koutinas AF, Solano-Gallego L, Bourdeau P, Ferrer L: Canine leishmaniosis new concepts and insights on an expanding zoonosis: part one. Trends Parasitol 2008; 24: M iró G, Cardoso L, Pennisi MG, Oliva G, Baneth G: Canine leishmaniosis new concepts and insights on an expanding zoonosis: part two. Trends Parasitol 2008; 24(8): S olano-gallego L, Koutinas AF, Miro G, Cardoso L, Pennisi MG, Ferrer L, Bourdeau P, Oliva G, Baneth G: Directions for the diagnosis, clinical staging, treatment and prevention of canine leishmaniosis. Vet Parasitol 2009; 165:1 18 S olano-gallego L, Miró G, Koutinas AF, Cardoso L, Pennisi MG, Ferrer L, Bourdeau P, Oliva G, Baneth G: LeishVet guidelines for the practical management of canine leish maniosis. Parasites & Vectors 2011; 4:86. Prevention 13

LEISHVET GUIDELINES FOR THE PRACTICAL MANAGEMENT OF CANINE LEISHMANIOSIS (CanL) About LeishVet LeishVet is a group of veterinary scientists from academic institutes in Europe and the Mediterranean

14 LEISHVET GUIDELINES FOR THE PRACTICAL MANAGEMENT OF CANINE LEISHMANIOSIS (CanL) About LeishVet LeishVet is a group of veterinary scientists from academic institutes in Europe and the Mediterranean basin with a main clinical and scientific interest in CanL. LeishVet s main goal is to improve the knowledge on different aspects of leishmaniosis in veterinary medicine and public health, including the development of consensus recommendations based on recent evidence-based literature and clinical experience that would represent the most current understanding of L. infantum infection in dogs and other animals. LeishVet Members G. Baneth Hebrew University, Rehovot, Israel P. Bourdeau Ecole Nationale Vétérinaire, Agroalimentaire et de l Alimentation, Nantes-Atlantique (ONIRIS), Nantes, France L. Cardoso University of Trás-os-Montes e Alto Douro, Vila Real, Portugal L. Ferrer Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallés (Barcelona), Spain A. F. Koutinas Aristotle University of Thessaloniki, Thessaloniki, Greece G. Miró Universidad Complutense de Madrid, Madrid, Spain G. Oliva Universita di Napoli, Napoli, Italy M. G. Pennisi University of Messina, Messina, Italy L. Solano-Gallego Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallés (Barcelona), Spain 14

15 About LeishVet 15

16 Mailing address: LeishVet, Veterinary Faculty, Universidad Complutense de Madrid, Av. Puerta de Hierro s/n, Madrid, Spain Web page: 1st Edition October 2011 Sponsorship: Bayer Animal Health

Proceedings of the World Small Animal Veterinary Association Sydney, Australia 2007

Proceedings of the World Small Animal Veterinary Association Sydney, Australia 2007 Hosted by: Australian Small Animal Veterinary Association (ASAVA) Australian Small Animal Veterinary Association (ASAVA)