Hello everyone. My name is Victor Lenovich, and I'm a vet with 10 years' experience in treating companion animals. I graduated from the Faculty of Veterinary Medicine in Belgrade in 2014.
My first clinical job was in, country of Montenegro, so I had to move countries to get my first clinical experience, and, my job in Montenegro is actually important for this presentation because it's a country that's, endemic for life many years. After my time in Montenegro, I moved to New Zealand and I worked there for 2.5 years.
Of course, there is no life there, but then I came back to my home country, Serbia, and, I'm working here for the past 4 years as a head veterinarian in the clinic, and, Serbia is geographically interesting for this presentation because it's a country that's at risk of becoming endemic and we will go through all those stages. During our lecture here. So, let's begin with lamaniosis.
What is le meiosis? Leish meiosis is a disease. It's caused by a protozoan parasites, so a single-celled organism, and it's primarily found in dogs, but it can also be found in cats, certain rodents, and humans.
It's mainly, it's present in many parts of the world, and it's most commonly present in rural areas, and that presents a big difficulty when it comes to preventing, diagnosing and treating le meiosis in general. So where can we find it around the world? According to geographical distribution, as you can see on this map, it can be found in approximately 50 countries, and the number of infected dogs is reaching millions.
But as I said before, because of the difficulty of controlling and diagnosing the disease, the number of infected animals could be much, much greater. So we can find it in the 4 continents that are considered endemic and the reports. Of the inspection of the expansion of the disease include countries like Brazil, Morocco, Tunisia, as I said before, Montenegro, so that's also Greece, Italy.
And all of the countries that have a mild climate. And the factors that are Important for the disease, spreading is migration, drought, deforestation, global warming, because I, I underline global warming because it's one of the main factors, and they have all been pointed out as reasons for the expansion into the areas where it had been absent, and I'm sure that we can all feel. The effects of global warming wherever we are.
So that all affects the spread of the diseases, not just like meosis, but many other diseases as well. So, I want to say a bit about the importance of sandflies. So, the main way a dog or a cat or other animals get infected with leshmaniosis is through sand ply vectors, and they are important for Leishmania life cycle.
And on this map now, we can see the geographical distribution of the sandli's habitat. And if we compare, compare it to the map from the previous slide. We can clearly see why they are so important because most of the countries that are presented here in red are also presented in the previous map where we have the presence of news in.
And now we can say we can start talking about Leman life cycle. The life cycle of leosis is alternating between two main morphological forms of the parasite. So intracellular ammatic gods are found in mammalian hosts, and motile prosti gods are found in the same fly vector.
Dogs will get infected. Dogs without, with or without clinical signs are infectious to send flies and can transmit with many parasites. And that's another reason why it's so difficult to control.
So, continuing. When acent flight fly bites an infected animal, it's going to become infected because it ingests blood that contains macrophages that have amagus inside of them. In the middle part of the fly gut, the meat gut.
Amati goods will develop into prosty goods. So in the flight may get, the promised the goods will multiply, develop, and then migrate to the fly mild parts. And you can see on the first picture here, it underlines the complete life cycle of placements we started.
With the dog, the scent bit bites the dog and then. It goes up. The main difference between promasticos and Amatigo in their appearance and what you will see in the clinic is only amatigo, and promosticos will be present only in the same 5 vectors.
So the one that gets the flagella behind them are not something that you will be able to diagnose in the clinic. So the last picture. On the bottom right is something that you can see after doing the cytology.
We will go a little bit later. And then once the scently who was infected by a by biting the dog and has accumulated the large number of romatics inside, bites, another dog or another animal, they're going to become infected with Lamaniaromatics. So, the sandflies are not the only method for that largemania can be transmitted from one animal to another.
So non-bacterial modalities of transmissions have also been demonstrated. So first one is sexual, another one is vertical, and also blood transfusion. For us as cognicians, sexual and blood transfusion are the most important because we can.
Influence the transmission there. So if we have a situation where a breather wants to Do you have a Artificial insemination or natural insemination and brings in the dog for a checkup before they do that, we should always test for menusis if we live in an endemic area. So if we are not in endemic areas, that's not something that's that important, but in endemic areas, we should always do that.
And of course, before every transfusion. The donor must be tested and of course come back negative. Another thing that I found in the literature is that There have been reported cases of transmission between dogs who live in the same household, and there, that's the only method of contact between them.
So those were neutered. There was no sexual activity, but only sharing foods and water bottles and in-house piping, was presented as a method of transmitting the disease. So what happens once the promatigos enter the whole life?
Upon infection, the post microphages will ingest Leshmania from mastigots. And that's an important thing to remember from this slide because the Leshmania Promati goods and then later Ramastigots will hide from the immune system and from the medication inside the cells, so inside the Macrophages and other immune cells that are, that are supposed to eliminate that. So once Leishmania enters.
The macrophages is going to transform from promatic goods to amastic goods, and they're going to multiply. Inside the macrophages cell. Once the parasitic burden is too high, the macrofiris will burst and release a large number of amass, and that's how they disseminate using the Cells of the mononuclear phagocate system, mainly in the blood, liver, s spleen, and bone marrow.
I that. Once they start disseminating, the incubation period may last for months until 2 years, during which the parasite will disseminate throughout his body, primarily using the hemolymphatic system organs. It is a common occurrence, and I have seen this many times in the clinic that patients get infected during the summer.
And don't start showing symptoms until the following winter, and that's how I came with the title for this presentation. So, During the summer, they will go on a vacation. The owner will probably forget.
Use preventative methods and then January, February, so the following winter, they will come in the clinic showing typical symptoms of le meiosis. So air breath cause genetics, nutrition, concurrent infections and non-infectious diseases are other and other factors will also influence the progression from infection to clinical disease. So clinical findings are we going to encounter in the clinic?
And Lamania is A bit difficult to diagnose, so we need to understand how it progresses through the body and we need to take into consideration where meiosis when we have A symptom that's not really fitting with other diseases and Also, during an amnesis we will discover if there was miss in preventative methods. So there are 3 main types of, leishmaniosis infection can present itself. So the first one is general or wear leishmaniasis, and we will go over that in detail.
After that, we have cutaneous le meiosis and finally oculi. So these, these three types are not excluding each other, so they will be. They can be present, all three of them in the same animal, but you can have only one or only one symptom of.
One of these 3 types, and that's, that can be enough for us to get our diagnosis correct. So general le meiosis or Westerlemanosis as I said before, I listed here all of the symptoms that can appear in that form but generalised lymphadenomegaly, loss of body weight, changes in appetite, and splenomegaly are something that I have encountered in the clinic many times. So that's something that It's most likely to be presented.
When you, when you examine the dog. Other symptoms like lethargy, polyuria, polydipsia, mucous membrane ellar, fever, vomiting, diarrhoea, so they are, they are all symptoms that can appear in a dog with flesh menu, but they are very similar to other. And diseases and other conditions, so it's Not something that will point us immediately towards laman when we examine the block.
Procutaneous finding can be fine. So non-prutic exfoliated dermatitis with orbitallopecia, so. We will have a dog that has a very dry and flaky skin.
The poor quality of coat and LC is usually symmetrical on the sides of the body. So in the rib cage or a bit behind, and it, it can be quite often symmetrical, and that's one thing that when we see should always make us think it could be less menus. Erotic dermatitis and nasal hip or keratosis.
Also with oneoerosis is something that I again underlined here because I have seen it quite a lot in the clinic. And when we see, when we look at this black clot, on the bottom with hip keratosis on the nose, and that's something that's very characteristic for la meiosis. So I have seen dogs that present with this as the only symptom.
So they come in, the nose looks like that. There is no other symptoms and if you do a test, we can get a positive result. Apart from that, we can get no nodular dermatitis, papular dermatitis, posterar dermatitis.
So all kinds of skin problems can present themselves and of course, they can be little complicated with . Other diseases, so bacterial infections can present itself on the, on the feet and with the overgrowing nails like chronicopos, we can have fungus. And it all kind of intertwins, but the main problem will be like meiosis, so the treatment, if we treat only the secondary problem, it will not going to be as effective as it should.
Cochlear findings are not that common in Englishman uses, but they can present themselves. So blepharitis, exfoliative ultra or nodular, so it's similar to the dermatitis, but it's around the eyes, conjunctivitis also nodular as you can see on the picture in the middle, kerato conjunctivitis, common or anterior ulitis, and endoalittis. So all of this.
Is mainly focused on dogs because dogs are our main patients when it comes to plash meiosis. And these symptoms can be present as a symptom, but it's not that common usually. They are part of a complex array of symptoms that A patient comes in and presents itself and can be diagnosed like me.
So other findings in those, and these are atypical findings and something that can completely throw us off when we, when we see a patient like this doing, do an exam and they're not going to be. Present, with the typical signs of flash meiosis. So this is something that we need to think about.
And so mm mucosal alternative or nodular lesions, oral, nasal or genital epistaxis, lameness, atrophic masticatoryuitus, vasculatory disorders like vasculitis, arterial or romboembolism, and neurological disorders even. So it has a neurological form, but it's very rare. And, an anecdote from this place in a situation where, I was a junior with in the clinic in Montenegro and I had a patient that was a similar like with the dog that is showing a bit of a lameness on the, on the, on the picture here.
So a big Breed dogs, love breed dog with the, I, I remember it was a black dog, so it presents itself at the 6 months of age and the only symptom he had was lameness. So I was thinking if he was too young to get infected from, Same place and I was examining the dog and the senior re come by it. Ask me what's happening and I was like, we have a laus here, and he looks at the dog, didn't even examine it and say, maybe you should do a la meiosis test.
And what happened there, the test came back positive. And then when we talked about it, and then, it happened that we had a case of vertical transmission of meiosis from so the, the dog got it from her mother, and the only symptom presented was lameness. So we treated the dog and everything was.
Concluded positively for, for the dog and it was just the, the beginning of the disease. So that's something that can happen and it has happened to me before. Also, the dog with masticatory immunitis, is something I have seen in the clinic, not much, but once or twice, but that was enough.
And, if we didn't test for leosis, the outcome would not be positive. So when it comes to cats, we will not talk a lot about cats, and I will explain why. But, feline enlargement osis is also a chronic disease, and the most common clinical findings are similar to those in dogs.
I will not repeat myself. We just need to look at the dogs. So sand flights, they can get infected from cats, and that's the importance of the disease here and they can transmit the infection to dogs.
And unlike dogs, non-victorial transmissions has not been described, which doesn't mean it's not going to be present. It is, it doesn't mean it's impossible. It doesn't mean it, it hasn't been described, but leosis in skets is much less likely, much less present than dogs, and the most common presentations will include Cutaneous lesions and you can see several pictures here and all of those from my point of view as a clinician can look like something else and not lesion use in kids.
Oral lesions, especially I have seen many lesions like that that were not caused by. Le meiosis and at the end, uitis is the most important ocular lesion in cats and that's going to happen only in the progressive form of the disease. So what's the importance of meiosis in kids?
But So here in Europe, there have been just over 100 reported cases of feline enlargement osis in the last 30 years. So as I said, there is not really that many cases, but And the disease can be easily overlooked because of concurrent HIV, FELV infection, or it can be misdiagnosed due to similarities to other conditions. We saw it before and we will see it again, so most of these kids, when we look at them, at the first glance, it will look like something else.
But the thing is that the cats can be a source of infection or sandflies, and they can later infect those. So here are the laboratory abnormalities that we can find once we test dogs with life mans. So most of these we have in the clinic and we should always do complete blood count and also biochemistry analysis.
So what I underline here is something that when I see in the results will point me towards flash my music, so. Himia, hypoinemia, hepatoglobulinemia. Hippo albuminia, so decreased albumin global ratio, that's an important one to remember, so if it's decreased, so that's the The consequence of the body battling the infection and just expanding the Immunoglobulins and so the ratio is going to be affected by that also renal azothenia.
So the kidneys are the organ that's mostly affected by lemannia infection. So other symptoms are non-re anaemia, leukocytosis or leukopenia, which is something that can confuse us clinicians, thrombocytopenia, impaired secondary hemostasis and fibrinolysis, and also elevated liver enzymes and proteinuria, which will also be because of the kidney problems, right. Compared to dogs, cats don't have that much, that many symptoms or that many abnormalities in their lab work.
So neurodegenerative anaemia, monoyosis, neutrophilia, pancytopenia, hyper gamma globu anaemia, hypoglomia, azotemia, proteinuria, a role. Findings that be, that can be present. In the in the movies.
So how do we go about diagnosing the disease? So diagnostic approach. Diagnostic tests for can enlargementosis include complete blood count by chemistry profile urinalysis, and one or more specific tests to confirm infection.
And when we talk about Specific tests, quantitative serology is the best used for diagnosis, it is particularly sensitive, and A compatible clinical signs are present. So high antibody titers were found in 80 to 100% of those with clinical disease and could be conclusive of diagnosis. So that's .
An approach that I found in the literature, but, from a clinician point of own point of view, if we get a positive test, we don't need to think more about whether it is a false positive or not. So once we have a positive test for meiosis, that's quite enough for us to start treatment, and we shouldn't have any, any problems later on, and we shouldn't think about if we misdiagnosed. Or something, so.
When it comes to quantitative serological matters to the deck. Anti-L Leishmania antibodies, a lot of them have been developed, including Indirect team of Florence essays, Eliza, and direct hallucination essays. So all of these listed here are something that we will have to send a sample to the laboratory for.
So we send it to the lab to the one that they have that's best for them and we get the result, and that's quite enough. But let's say that we live in a pandemic area and we are very likely to get lots of mania cases and what we should do is get Rapid flow tests like purified recombinant antigens such as RK 39, they can be used to detect lash meiosis in dogs. People in several rapid tests have been.
Have been made. So from my point of view, we had one of those rapid flows and began an peak body tests, in the clinic, and that's something that we used almost exclusively, and we never had any problems when when it comes to false negative results, sorry, false, false positive results. If we get the negative result on the rapid antibody.
Antibody tests, then we may repeat the test or we will send it to the lab and do one of the tests you described above. But, if we get the positive tests, there is no reason to think more about the diagnosis we have or the diagnosis confirmed and we start thinking about treatment and . We will go over that a bit later.
So, when we are in the clinic and we get the Patients that comes in and how do we go about. Diagnosing it. So this here what I've shown you is the most difficult presentation of leishmannuosis.
So you get the Patient in the clinic and it comes in check it and bringing his tail he is behaving just like if he came in for a vaccination or a regular checkup, so you, you can't tell by the dog's behaviour that he's sick. So that's something that was always very strange to me. But, because when you look at the dog, you can see that there is a problem, but compared to his behaviour, it, it was completely normal.
So it's bright alert responsive. And also, the, the owner will report that the dog is, happy, eats normally, and keeps losing weight. So we can see that this dog has lost quite a lot of weight, but, especially in the back parts of the body.
So his head and his neck are usually not that much effect. So he, he, he will usually, it doesn't, it's not necessarily a rule, but this kind of dog will, will usually have a poor quality coat. The skin would be dry and flaky, and lymphadenomegaly is present, but in my experience, It's most noted with the polial lymph nodes.
And here in the picture, which is something that shouldn't happen in a healthy dog, you can actually see the polial lymph nodes behind its knees are baulking and if you try to palpate them, you will see that they are grossly enlarged. And when you get, do an exam like this, you should always think about doing the test. And once you do a rapid antibody test, you will get the most likely get a positive result and that's enough to confirm the diagnosis.
And then we saw what the typical case was. And then when it comes to atypical cases which can present, they are not that common, but, we shouldn't be relaxed when it comes to these cases, especially if you live in endemic areas, or if when talking to the owner and getting the analysis, the owner reports, they spend a significant amount of time in the endemic area and then came back home. Especially during san fly season.
So that's something that we need to keep in mind. So the first picture of the black dog with the skin issues on the nose, at the first glance with coin, it was lupus or it was bacterial hematitis. And what is misleading in most of these cases is that they are going to have a secondary bacterial infection and if we tested for for bacterial infection, it will come back positive.
So we are going to treat, but we are not going to get the results that we expect when it comes to something. When it comes to cases like this, so we will take care of the bacterial infection that the problem is not going to go away because this money is not responsive to antibiotics and The, the problem is not going to go away. Again, here we can see on this second dog that he is symmetrical alopecia.
On the sides of his body, which is characteristic to, leishmanosis, but it can also be present in demobiosis and it can mislead us, to think. We have just a simple dermodex case which can be easily, easily resolved. Also, the nodular dermatipe is on the lips and Skin issues on the hind legs of this dog, also not bacterial and not the yoderma as it would look like on the first glance.
So when it comes to ocular symptoms, as I said before, they are not that common, but, they should be approached cautiously. If there is only an ocular symptom and you live in endemic areas or there has been, an exposure reported, And again, if it's not reacting to treatment as it should, then we should think about doing the test for life money as you and if we have available those rapid tests, they are very cost effective. So I think we should be doing them more than trying to skip them for whatever reason.
So cytology here from my point of view is quite an interesting tool. It can be very useful, but it can also be disappointing. So Leishmania Amati goods can be demonstrated from lymph nodes, spleen, skin impression, bone marrow, or joint fluids, and they are stained with GSA or quick commercial stain.
So from my clinical experience, if we do FNA of a lymph node, and we just do . Quick commercial stain in the clinic. It is possible that you will get A positive result just like it's here on the pictures and we, if we find amas then it's that confirms the infection, but .
Detection of Amagots by cytology is sometimes unrewarding because of the low number of detectable parasites, even those with a full-blown clinical disease. So that is something to be aware of and we do cytology. So the, which many parasites may also be viewed in histopathological form of fixed paraffin embedded by a C-section of the skin or other infected organs.
So that's something that's done in the lab, so that's not, not something that we are going to be doing. In-house, but another case that I had happened to me in the clinic is where I had the dog that clearly. That was presented with Typical symptoms of le meiosis and I did the test and the test was negative, which was obviously a false negative result for the rapid antibody test and it occurred to me to do NFNA of the poli lymph node and I got the positive result from there and the picture most resembling the result is the first time here on the slide.
So there was macro the full of Leishmania Hamas. And then once we have a diagnosis, we have to consider treatment options. So the main medication for or the main combination of drugs for like meiosis.
He's Glucantium and that's meglomin animmonia as a drug the dose is 50 to 100 milligrammes per kilogramme and it applied subcutaneously for 4 to 6 weeks. In my opinion, sorry, in my experience in the clinic, 4 weeks was usually not. Rarely, we would get the, the need to extend it for 6 weeks of treatment and the symptoms would disappear within 2 or 3 weeks and then we do the 44 weeks treatment and that was most commonly quite enough for the patient.
And it's always combined, combined with allopurinol that's be given orally, twice a day for 6 to 12 months or longer as needed. So the way we did it back at the clinic because there was a problem getting glucantin or other medication to treat le meiosis and allopurinol was readily available, we would start with the animals immediately. We want allopurinol.
While they wait for the other medication to to arrive. And the problem with le meiosis, and that's why this disease is so difficult to control if the treatment frequently does not provide a sterilising cure. Treed dogs will remain carriers of infection and may relapse.
They are also, they are also likely to remain infectious the same price. So we will have a clinically healthy dog that has undergone treatment. But he will possibly still be infected, infectious for sandflies and spread of the infection.
So alternative treatment for glucatine is milteosin and we should decide one or the other mainly for depending on the availability of the medication. And it's also combined with allopurinol. The milhosin is given also orally at 2 milligrammes per kilogramme per day.
And it's used for 4 weeks, so the, it's similar to gluantine but I didn't have much experience with it was because antin was much easier to, to get in the clinic. The additional treatment is symptomatic or immune-potentiating treatment, and it's depending on the individual needs of the patient and the stage of le mesis when we get the diagnosis. The key parameter in deciding the treatment route is the condition of the patient's kidneys.
And now we will go over the treatments when it comes to different stages of the disease. So stage one is a mild disease. Here in this stage, the clinical signs are either absent or very mild.
Usually they are in the form of a dermatitis or generalised clinhodenomegaly. Again, I'm getting bored with the lymph nodes, but it's something that I have seen, . In the clinic that will always point me towards slash meiosis.
And laboratory findings are usually completely normal. Serology is quite often. Negative or low positive.
In my opinion, it's usually, a low positive result. And the treatment options in this case should be discussed with the owner, and they can choose to do the treatment or just monitor every 3 to 6 months. So, repeat the serology, repeat the laboratory findings, and if the disease starts progressing, then we should apply treatment or not, we can just monitor and postpone treating for another 3 to 6 months.
If the if the owner decides to do the treatment then. We do a course of antin or proposing and we combined it to allopurinol. Allopurinol, in this case, it's enough to do for 6 months and then we continue the monitoring, twice a year.
The prognosis in this case is quite often good. So the second stage is something that we are going to see, most commonly in the clinic. So we will tell diffuser symmetrical, symmetricalcutaneous lesions, generalised lymphadenomegaly, appetite changes, and weight loss.
Laboratory findings will be compatible with le meiosis, and we should remember the ones that I underlined. That's something that you're going to see in a case like this and in this stage. The kidney condition in this case or in this stage is usually normal.
Or we can have a bit of protein nea, a bit of elevated creatinine, and the UPC is a bit slightly elevated but usually pretty much OK, so 0.5 to 1. Theological findings are usually positive and the treatment should always be applied upon diagnosis because this, from this stage the without treatment, the disease is just going to keep progress.
So we do a course of gluconine and milloin and always combine it with allopurinol. In case of compromised kidney functions, we should refer to high risk kidney guidelines for CCD and the prognosis in these cases are usually, usually good, but Depending on the patient, we should say it's guarded but From my experience, you, you have a positive result. So, stage 3 of the disease, that's when it has progressed quite a lot.
And we have a clinical picture like showing like it's shown here and symptoms that are present in stages 1 and 2 are also present here, but we also have Symptoms that originate from immune complex depositions such as glomerulo nephritis or uveitis. And this is something that's seen in both dogs and cats. And once we have glomeru nephritis, the kidney function will be compromised.
The laboratory findings are compatible with leishmaniosis, and we will have more of those that are listed in the, in the slide previous to this. And the kidney condition will have a clear . And the dog will have a clear CTD stage either 1 or 2, so the UPC will be above 1, the creatinine is going to rise.
Treatment in this case, so always we need to treat the, the initial problems, so we use glucantine or the poin combined it with allopurinol. We follow strictly Iri kidney, CKD guidelines for stage 1 or 2. And then on top of all of that, we need to apply a symptomatic treatment, as needed and depending on the needs of the patient.
And in this case, the prognosis. It is worse compared to the previous two. So it's going to be either guarded or poor and mainly it depends on how the patient will react to the treatment, both symptomatic and causal treatment and once we Start the treatment and see how the patient react.
That's when we should do, give our prognosis and not before. And the final stage, it's a very severe disease. So all of the clinical scientists that were listed before, so stages 1 to 3, and the patient will also develop pulmonary tramboembolism, nephrotic syndrome and end stage kidney disease.
In this case, the laboratory abnormalities will be severe. We will have most likely all of the laboratory findings listed before, and they are all compatible with Leishmaniosis. The kidney condition, it will be end stage kidney disease, or 3 or 4, the UPC will be above 5.
The creatinine will rise quite a lot, and it's going to have a mark nephrotic syndrome. So initiating treatment will depend on the severity of the kidney disease and general condition of the patient. When I say if applicable is because we should have a discussion with the owner and I know it is a difficult discussion to have, but in this case it's going to have to happen, and we need to inform the owner that it is most likely that.
This dog will not survive even with treatment, so we should recommend putting it down, but it also. It depends on the owner's decision as well. So, you can have a, a positive outcome even in this case, but it's not going to be in that many.
Cases like, like before, so you up to the stage 3, you can do a likely a positive outcome in this final stage. It's very unlikely that the dog will survive with treatment. If we, if we can, we do just the same treatment, we can continuehosin and combine it with allopurinol.
Also, we will do the CKD treatment is. Described in the Irish Irish guidelines. So when it comes to treatment in kids, And there are no published controlled studies for treatment of feline large menuosis.
So in the absence of evidence that suggests otherwise, we will use the same protocol as in dogs. So we just go through the same stages like we do in dogs, and the cats tend to be more prone to kidney problems. I'm sure everyone has seen this in the clinic.
And so we should monitor the kidney function even more frequently and be more, more aware of that. So additional treatment for le meiosis is in addition to the primary cause of treatment, we should use immune potential treatment and the drugs that I have found that are useful are toperidone, so nucleotide plus AHCC, and this treatment can be used alone, but it's only in the stage one of the disease where there are no clinical signs or or laboratory abnormalities. Just to have a positive test and in subsequent stages, we should always monitor kidney function and if the kidney function permits, I would use all of this because it's going to give us a better chance of the positive outcome.
And now we should go through the potential side effects of the treatment. There are not many and they are usually well tolerated, but we should be aware that it can happen. So with gluconine, it's given subcutaneously, so.
We can have pain and inflammation on the injection site and potential nephrotoxicity, so I haven't encountered that, in any of my patients as a, as a consequence of gluconine, but we should be aware that it is possible. So for nephrotoxicity, we can't do really anything, but, for pain and inflammation in the injection site, we can just, . Give injections at different sites and monitor the patient, so we go case by case.
For millosin, we will have eating disorders, vomiting, and diarrhoea. That's because it's an oral medication and we should always give it the food and if the problem persists, we just, go about it like with any other oral medication that's causing eating disorders, so we give it with food or we Use antiacids or? So so continuing allopurinol, and I have seen this in the clinic, but not that often, is that something neuralidiasis and renal mineralization.
And that's happened only in cases where the dog has been taking allopurinol for more than 6 months. So in the 1st 6 months, it usually doesn't happen, but we should be aware that it can happen and we should just monitor with urinalysis and abdominal abdominal ultrasound and, from my point of view, every 3 months, we just do a bladder ultrasound and a renal ultrasound and that's going to be quite enough. So when it comes to Domperidone, Galacteria is, potential symptom if it starts causing problems, we just stop, stop the treatment.
And now we go to long-term monitoring. So the monitoring parameters are History of physical examination and then we do the laboratory. Examination like we should do in any other case.
So we do CBC biochemistry profile, and we always should pay close attention to the kidney parameters. We do complete urinalysis and the UPC. So as I said before, the kidneys are are the organ that's mostly affected by leosis, so we should always be.
Monitoring them more closely compared to the other organs. So Quantitative serology. Some doctors have treated.
Have significant drops in the antibody levels within 6 to 12 months of treatment along with the clinical improvement. So that's something that we should include in our long-term monitoring and after. That's if we encounter a marked increase in antibody levels in those in those dogs, we should consider that to be a relapse and especially if we stop the treatment.
So it can happen, as I said before, the treatment unfortunately doesn't provide a sterilising cure, so the largemania can relapse and We can use real-time PCR but I just want to say here that it is something that we can use, but I haven't personally used it in the, in the clinic. And so monitoring, how often should we do? With the clinically healthy infected dogs, so that's stage one of the disease.
We do it every 3 to 6 months. So if, if we have a sick dog that has undergone treatment, after the first month of therapy. We should do one course of monitoring and then after that, we continue every 3 to 4 months for the first year and then after that, Once they have fully clinically recovered and we stopped treatment, then we should do it every 6 to 12 months and that's connected to the slide before where we said that, .
There can, it can happen that they have a marked increase in the antibody levels, which is something that we should consider a relapse even if the dog doesn't show any, any additional symptoms. So how do we prevent la meiosis? It is difficult to prevent, but the main thing we can do is, to prevent the same flight from biting an animal.
So the prevention methods available are re repellents and vaccines. So animals can be protected from le meiosis by applying one or multiple topical insecticides during the periods of the scentli activity. Animals that live outside of endemic areas and that's something we, we should always discuss with the owner if we live outside of endemic area and we know that they plan to travel in an endemic area that they should.
Always be protected and From my point of view, we should combine at least two methods of protection against the sandflies biting. So quite a lot of them, and that's something that usually happens is that an owner will take their dog, for vacation and they will go to see. And that That climate is beneficial to sandflies, so the dog can come back infected and this, this repellents are usually sensitive to water.
So if the dog goes to to the seaside, it goes in the water, the effectiveness of the repellent is going to be diminished and . They can suffer from sand fly bites and potentially get infected. So I would recommend combining at least two types of of repellents where.
Very applicable, very possible. So in the areas at risk of becoming endemic, it is recommended to always apply protection during the scent flight activity periods. In endemic areas, on top of the scently repellents, we should always recommend vaccination.
So if you live outside of the endemic areas, I don't see a point in using the vaccines, but we should recommend the protection against sandflies and it's Quite easy to do because The sandfli repellents are usually not just for sandflies, they are treatment for fleas, pigs, mosquitoes, and then they will include scently protection. So during the activity periods, we should recommend the use of repellents, but the vaccination is something that we should recommend only in endemic areas. And in this picture, we can see the Life cycle of sandflies and their activity periods.
So in tropical areas, some species are present in the whole year and in temperate regions, adult sandflies are only present during the summer. So in tropical areas, you should recommend protection for your round. What I did in the clinic because in Montenegro we had cases all year round.
I would recommend the repellents to be used, . The older and then during the Peak of activity. So during the summer months, I would recommend to double or even triple the, the repellent protection.
And there was a time where the vaccine wasn't available, so we didn't do it but Once he became registered in Montenegro, we started vaccinating and that really helped. So, again, with prevention, insecticides that are efficient in the prevention of life noosis are permetrin spot on products that usually will provide protection for 3 to 4 weeks. Deltametrine impregnated colours are usually effective for up to 12 months, and lumerine are usually effective for up to 8 months.
So with these colours, in my experience, let's say. 7 months of full protection is something that's quite common, with, these colours, and, I would recommend, Replacing them every 7 months because they are not just protecting against sandflies, they are protecting other from other active parasites, and, we need to take that into consideration as well. So spot on products should be applied at least 2 days before we expect exposure and callers, they need time to start working properly, so 1 to 2 weeks, and from my point of view, 2 weeks is, is better.
In endemic areas, we should always recommend repellents all year round and in the months with peak activities of sand flights, we will combine cos and spot on products. And now we come to vaccination. There is only one commercially available vaccine in Europe that I was able to find, so plenti filled with protein as an active substance.
Vaccines do not prevent infection, but will reduce the probability of clinical disease development. So what does that mean for us as clinicians? So, if we use only vaccination to prevent the leishmaniosis, we will protect the vaccinated dog and only him from leishmaniosis and he's going to become infected and he's going to help spread the disease.
So we should never recommend. Or using only vaccination. We should recommend using vaccination and repellent.
As a combination of treatment because we won't stop the dog getting infected in the first place, but if it does get infected, the Leishmania vaccination is going to stop the clinical disease from And becoming active. And for dogs that live in endemic areas, a multimodal approach is recommended, as I said, and we would always. Combined vaccination and repellent.
So for the vaccine. It is usually given as one in initial vaccine with an annual booster. The vaccine is effective in 72% of cases in preventing the onset of clinical disease.
So. The, I used to wonder why do we have a vaccination that's not going to prevent the infection, but when you think about it, we need to stop the infection of the disease for From becoming clinical and if we stop, if we use protection or repellents against sandflies, even if the dog is infected, it's going to be, it's going to limit. The spread of disease quite significantly.
So it can be given to a healthy set of negative dogs, that are at least 6 months or older. Again, I come back to the dog that I saw in the clinic that was 6 months and he was lame and we diagnosed it he was positive for leishmanosis. In that case, again, I would recommend vaccinating the dog after the Finishing, after finishing the initial treatment because that's going to stop the progression and Relapse of the clinical symptoms and also we should do repellent to Stop sandflies from becoming infected from the dog and then spreading the disease.
So when it comes to meiosis, this is it. I hope that was. Effective for you.
I hope you learn something new and I hope you. You can use this in your clinic to diagnose more cases of ages. Thank you for your attention.