Leishmaniasis In Northeastern Brazil Research Articles

Chiropterans as a potential hosts of Leishmania spp. in endemic areas for leishmaniasis in northeastern Brazil.

The species of the genus Leishmania are protozoa that are widely distributed from Asia to the Americas, affecting humans and wild and domestic animals. Little is known about infection by Leishmania in bats in the state of Maranhão, Brazil. The objective of this study was to investigate the presence of Leishmania in bats in Maranhão. Blood samples were collected from bat species for parasitological diagnosis. Samples of spleen and liver were collected for molecular analysis. All the blood cultures were negative. In two blood smears, organisms similar to amastigotes of Leishmania sp. were detected. Of the 116 samples, two spleen samples were positive and showed similarity to Leishmania infantum. Therefore, further studies are needed to elucidate whether bats take part in the epidemiological chain of leishmaniasis.

Epidemiological and clinical factors associated with lethality from Human Visceral Leishmaniasis in Northeastern Brazil, 2007 to 2018.

ABSTRACTHuman Visceral Leishmaniasis (HVL) presents a subacute clinical evolution with systemic involvement, which can result in high case fatality, especially among untreated individuals or those with low socioeconomic status. This study aimed to identify epidemiological and clinical factors associated with HVL case fatality in the Ceara State, from 2007 to 2018. This is an analytical cross-sectional study. The bivariate analysis was performed by Stata 15.1 using Pearson’s Chi-square or Fisher’s exact test; and Poisson regression for age-controlled multivariate analysis. From 2007 to 2018, there were 4,863 new confirmed cases and 343 deaths from HVL (case fatality rate=7.05%). The risk factors associated with case fatalities were: age group (RR=8.69; 95%CI:3.56-21.20); black population (RR=2.21; 95%CI:1.45-3.35); jaundice symptoms (RR=1.72; 95%CI:1.38-2.14); edema (RR=2.62; 95%CI:2.10-3.26) and hemorrhagic phenomena (RR=1.63; 95%CI:1.26-2.10); and no prescription drug intake (RR=4.03; 95%CI:2.98-5.46). Treatment with pentavalent antimonial was a protective factor (RR=0.35; 95%CI:0.27-0.45). The number of deaths increased among the elderly, illiterate, urban residents, and black skin color individuals. The drugs pentavalent antimonial and amphotericin B showed an association with death, but were not considered causal factors. Treatment failure led to a high risk of death. In multivariate analysis, the risk factors for fatal cases were age group, black skin, symptoms of jaundice, edema and hemorrhagic phenomena; and failure to take the prescription drugs. Treatment with pentavalent antimonial was shown to be a protective factor. Knowing the factors associated with the fatality of VL-HIV cases may help to improve public policies, in order to refine the epidemiological surveillance program and, consequently, prevent deaths related to the disease in Ceara.

Predominance of Leishmania (Leishmania) amazonensis DNA in Lutzomyia longipalpis sand flies (Diptera: Psychodidae) from an endemic area for leishmaniasis in Northeastern Brazil.

ABSTRACTLeishmaniasis is a serious public health concern in the Northeastern region of Brazil, where the sand fly fauna is well studied, although few species have been identified as competent vectors. The detection of Leishmania spp. parasites in wild-caught sand flies could help sanitary authorities draw strategies to avoid the transmission of the parasites and, therefore, the incidence of leishmaniases. We detected Leishmania DNA in wild-caught sand flies and correlated that data with aspects of sand fly ecology in the Caxias municipality, Maranhao State, Brazil. The sand flies were sampled in the peridomicile (open areas in the vicinity of human residences) and intradomicile (inside the residences) from July/2019 to March/2020. Leishmania DNA was detected in females, targeting a fragment of the Internal Transcribed Spacer (ITS1) from ribosomal DNA. Among the fourteen species of sand flies identified, five (Lutzomyia longipalpis, Nyssomyia whitmani, Evandromyia evandroi, Micropygomyia trinidadensis, and Micropygomyia quinquefer) harbored DNA of Leishmania (Leishmania) amazonensis. The most abundant species in rural (Ny. whitmani: 35.2% and Ev. evandroi: 32.4%) and urban areas (Lu. longipalpis: 89.8%) are the permissive vectors of L. (L.) amazonensis, especially Ny. whitmani, a known vector of causative agents of cutaneous leishmaniasis. Although Lu. longipalpis is the vector of L. (L.) infantum, which was not detected in this study, its permissiveness for the transmission of L. (L.) amazonensis has been reported. We suspect that visceral leishmaniasis and cutaneous leishmaniasis are caused by L. (L.) amazonensis, and the transmission may be occurring through Lu. longipalpis, at least in the urban area.

Maintenance and Productivity of a Lutzomyia longipalpis (Diptera: Psychodidae) Colony from an Area Endemic for Visceral and Cutaneous Leishmaniasis in Northeastern Brazil.

Studies on experimental sand fly infection require the availability of colonies and laboratory conditions. In Brazil, Lutzomyia longipalpis (Diptera: Psychodidae) (Lutz and Neiva 1912) is responsible for the highest infection rates by Leishmania spp. and this species is one of the most suitable species for laboratory colonization. In this study, we describe a method for growing Lu. longipalpis in laboratory conditions (10 generations) from natural populations sampled from a region of high endemicity for visceral leishmaniasis in the state of Maranhão, Northeastern Brazil. Using two methods (individualized or grouped females), the colony's highest productivity occurred in the first four generations, where all stages presented with high frequency. Nonviable eggs represented more than 50% of the total eggs produced by engorged females, while pupae were more resistant to fungal contamination, with a mortality rate of only 2%. In both methods, there was a predominance of female emergence; however, the ratio between males and females did not show significant differences, IF (P = 0.8023) and GF (P = 0.1831). Using the method of individualized females, the F4 generation took the longest to appear (234 d; 64 ± 57 d); by grouped females, F3 took the longest to appear (102 d; 47 ± 20 d). This method provides sufficient numbers of insects to perform vector competence tests for Leishmania spp. that cause the cutaneous form of leishmaniasis, usually found in Lu. longipalpis sampled from the study location.

Sandflies in an endemic area for Visceral Leishmaniasis in Northeastern Brazil.

Phlebotomines of the genus Lutzomyia are important vector for species of Leishmania, the etiological agent of leishmaniasis. The aim of this study was to assess the diversity of sandflies in an endemic area for Visceral Leishmaniasis (VL). Sampling was performed in four localities on the coast of the municipality of Goiana, state of Pernambuco, Northeastern Brazil. Specimens were collected monthly on three consecutive nights, from November 2017 to October 2018. CDC light traps were installed at a height of 1.5 m above the ground, in two ecotypes (i.e. tree and animal facility), both in peridomestic areas. A total of 5,205 sandflies were collected, among which the species Lutzomyia longipalpis (99.85%; 5,197/5,205) was the most common, followed by Lutzomyia evandroi (0.13%; 07/5,205) and Lutzomyia whitmani (0.02%; 01/5,205). Specimens of L. longipalpis were collected throughout the study period and most of them were found near to the animal facilities. The findings from this research indicate that vectors for Leishmania infantum are present in the study area throughout the year, along with occurrences of vectors relating to Cutaneous Leishmaniasis (CL). Preventive vector control measures need to be implemented in Goiana to reduce the risk of infection for the human and animal populations.

Changing epidemiology of visceral leishmaniasis in northeastern Brazil: a 25-year follow-up of an urban outbreak.

Visceral leishmaniasis (VL) continues to be a deadly parasitic disease in Brazil but the epidemiology has changed. The objective of this study was to assess the evolution of urban VL in the city of Natal, Brazil, over the past 25 y. A retrospective study of human VL was performed, considering reported cases over the past 25 y in Natal. Analyses considered the spatial distribution of VL cases, human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) co-infection, Leishmania infantum infection in dogs, density of the insect vector (Lutzomyia longipalpis) and socio-economic factors. Paralleling migration of the population, VL cases changed from mostly rural to predominantly urban regions. The incidence of human VL was highest during the initial years (1990-1994) of our study. Human VL was positively associated with a high density of L. longipalpis, a high prevalence of canine L. infantum infection and HIV/AIDS co-infection. The average age at diagnosis increased over prior years and males were more frequently affected. The overall fatality rate was 6%. Socio-economic variables indicative of poverty were associated with a greater incidence of VL and clusters of VL. VL has become endemic in Natal. The disease is associated with poverty and male gender. Surprisingly, there has been an increase in the age at diagnosis.

Environmental Factors and Ecosystems Associated with Canine Visceral Leishmaniasis in Northeastern Brazil.

Environment influences the composition, distribution, and behavior of the vectors and mammalian hosts involved in the transmission of visceral leishmaniasis (VL), affecting the epidemiology of the disease. In Brazil, the urbanization process and canine cases of VL are indicators for local health authorities. This study aimed to investigate the occurrence of the canine visceral leishmaniasis (CVL) in Maranhão State, Brazil. Blood samples collected from 960 dogs from six municipalities and six different ecosystems (Baixada Maranhense, Mangue, Mata dos Cocais, Amazônia, Cerrado, and Restinga) to serological tests (enzyme-linked immunosorbent assay [ELISA], indirect fluorescence antibody test [IFAT], and chromatographic immunoassay methods [Dual Path Platform technology, DPP(®)]) and parasitological diagnosis. From serological tests, 11.14% (107) of the dogs were positive for CVL, with 59.16% (568), 14.5% (148), and 131% (126) positives to ELISA, DPP, and IFAT tests, respectively. Only seven animals (0.73%) were positive in a parasitological test. We also performed parasite isolation and phylogenetic characterization. All isolates of dogs obtained from Maranhão were grouped in a single branch with Leishmania infantum chagasi from Brazil. The ecosystem Amazonia presented the highest positivity rates to CVL in serological and parasitological tests. Brazilian biomes/ecosystems suffer large degradation and may favor, depending on climatic conditions, the installation of new diseases. In the case of VL, dogs are reservoirs of parasites and sentinels for human infection.

Small mammals as hosts of Leishmania spp. in a highly endemic area for zoonotic leishmaniasis in north-eastern Brazil

Leishmania parasites cause leishmaniasis in humans and animals worldwide. These parasites are transmitted by phlebotomine sand flies, which become infected upon feeding on an infected mammalian host. We assessed the occurrence of Leishmania infection in small mammals in an area of cutaneous and visceral leishmaniasis endemicity. A total of 180 small mammals were trapped in 2003 and 2006 in a rural area in north-eastern Brazil. Spleen and skin samples from these animals were assessed by two PCR protocols, one targeting Leishmania (Viannia) spp. and other Leishmania (Leishmania) infantum. Additionally, serum samples were tested by an immunochromatographic test with rK39 as antigen. Overall, 23.2% (38/164) of the animals were positive to L. (V.) spp. and 8.8% (14/160) to L. (L.) infantum). Five animals of four species (Didelphis albiventris, Nectomys squamipes, Rattus rattus and Holochilus sciureus) were positive by both PCR protocols, an overall co-infection rate of 2.5%. By serology, 5% (7/139) of the animals were positive, but all of them were PCR-negative. An isolate obtained from a water rat (N. squamipes) was characterized as L. (V.) braziliensis (zymodeme Z-74). This study reinforces the involvement of different small mammals (e.g., N. squamipes, R. rattus and H. scieurus) in the transmission cycles of L. (V.) braziliensis and L. (L.) infantum in north-eastern Brazil. The finding of L. (V.) braziliensis infection in black rats suggests a rapid process of adaptation of a New World Leishmania species to an Old World rodent and raises interesting questions regarding the co-evolution of these parasites and their vertebrate hosts.

Ecology of Lutzomyia longipalpis in an area of visceral leishmaniasis transmission in north-eastern Brazil

Visceral leishmaniasis is a major public health issue in South America, where the disease is rapidly spreading. Changes in ecology and distribution of the principal vector, Lutzomyia longipalpis are among the factors accounting for the increasing incidence of the disease in this region. However, information about the ecology of L. longipalpis is still incipient, which may directly impair the implementation of effective control programs. Herein, the ecology of L. longipalpis was studied in a focus of visceral leishmaniasis in north-eastern Brazil. From August 2009 to August 2010, phlebotomine sand flies were monthly collected in four localities using CDC light traps (∼37 per month) and a lantern-baited Shannon trap with mouth aspirators. A total of 24,226 phlebotomine sand flies were collected with light traps and 375 with mouth aspirators. The most abundant species was L. longipalpis, representing 97.9% of the specimens collected with light traps and 91.5% with the mouth aspirator. Other species (Lutzomyia evandroi, Lutzomyia lenti and Lutzomyia sallesi) were found in low numbers. Most phlebotomine sand flies (94.6%) were collected at chicken coops and corrals. No significant correlation was found between the monthly abundance of phlebotomine sand flies and the monthly averages of temperature, relative humidity or rainfall. However, interestingly enough, 82.4% of L. longipalpis specimens were collected in months when relative humidity surpassed 75%. This study points out that this vector is well adapted to live in different habitats and to different climate conditions. It also suggests that some north-eastern populations of L. longipalpis may be more xerotolerant than southern populations. Further studies to assess the relationship between microclimate and L. longipalpis density in different Brazilian regions are advised.

Preventing Zoonotic Canine Leishmaniasis in Northeastern Brazil: Pet Attachment and Adoption of Community Leishmania Prevention

Visceral leishmaniasis (VL), caused by Leishmania infantum chagasi (L.i. chagasi syn. infantum) in northeastern Brazil, was responsible for 51,000 new VL cases from 1980 to 2003. Household presence of L. infantum-infected dogs is a major risk factor for human infection. Despite culling of dogs based on seropositivity, canine L. infantum seroprevalence remains near 20%, suggesting that dog culling is ineffective for preventing VL spread. We administered a cross-sectional survey to 224 households within 300 m of the homes of VL human patients diagnosed within the last year. The goal was to develop a model for voluntary preventative use based on characteristics and motivations of dog owners. We identified that owner knowledge deficiencies regarding canine transmission of L. infantum associated with increased risk of dog infection (odds ratio [OR] = 3.681, confidence interval [CI] = 1.223, 11.08). Higher owner education was associated with decreased levels of dog seropositivity (OR = 0.40, CI = 0.20, 0.81). Pet attachment (P = 0.036) and perception of risk/disease knowledge (P = 0.040) were significantly associated with willingness to voluntarily purchase canine VL prevention. These results highlight the importance of owner attachment to their pet in implementing reservoir-targeted zoonotic VL prevention.

Cutaneous leishmaniasis in northeastern Brazil: a critical appraisal of studies conducted in State of Pernambuco

American cutaneous leishmaniasis (ACL) is a complex disease with clinical and epidemiological features that may vary from region to region. In fact, at least seven different Leishmania species, including Leishmania (Viannia) braziliensis, Leishmania (Viannia) guyanensis, Leishmania (Viannia) lainsoni, Leishmania (Viannia) naiffi, Leishmania (Viannia) shawi, Leishmania (Viannia) lindenbergi, and Leishmania (Leishmania) amazonensis, have been implicated in the etiology of ACL in Brazil, and numerous phlebotomine sandfly species of the genus Lutzomyia have been regarded as putative or proven vectors. Because ACL is a focal disease, understanding the disease dynamics at the local level is essential for the implementation of more effective control measures. The present paper is a narrative review about the ACL epidemiology in Pernambuco, northeastern Brazil. Furthermore, the need for more effective diagnosis, treatment, control and prevention strategies for the affected populations is highlighted. This paper will provide researchers with a critical appraisal of ACL in Pernambuco. Hopefully, it will also be helpful for public health authorities to improve current control strategies against ACL at the state and country levels.

Serological evidence of Histoplasma capsulatum infection among dogs with leishmaniasis in Brazil

Histoplasmosis is a systemic infection caused by the fungus Histoplasma capsulatum. Environmental sources of infection for humans and animals in certain regions and the prevalence of infection in animals are frequently unknown. Because of the clinical and epidemiological similarities between histoplasmosis and leishmaniasis in northeastern Brazil, we decided to investigate the serologic evidence of H. capsulatum in dogs, considering that these animals can act as sentinels for histoplasmosis. A total of 224 serum samples from dogs were tested for antibodies against H. capsulatum through immunodiffusion. A total of 128 (57.14%) samples were positive for leishmaniasis by indirect immunofluorescence assay and four (1.78%) samples were positive for antibodies against H. capsulatum. Immunological evidence of the co-existence of histoplasmosis and leishmaniasis in dogs living in urban areas was observed. Diagnosis and clinical management of these diseases in endemic areas should be improved by veterinarians.

Climatic and demographic determinants of American visceral leishmaniasis in northeastern Brazil using remote sensing technology for environmental categorization of rain and region influences on leishmaniasis.

Remote sensing (RS) permits evaluation of spatial and temporal variables that can be used for vector-borne disease models. A Landsat Thematic Mapper scene covering Canindé, Ceará in northeastern Brazil (September 25, 1986) was spectrally enhanced and classified using ERDAS (Atlanta, GA) Imagine for 873 4-km2 areas. The population and number of cases of American visceral leishmaniasis (AVL) were determined for each 4-km2 area. Relative risk (RR) ratios were calculated for climate, demographic, and case data recorded for 17 years by the Municipality of Conidé. The RR of AVL for a child less than 10 years old from the foothills relative to non-foothill residency was 4.0 (95% confidence limit = 3.5, 4.5). The RR of AVL in children was 9.1 during a time when the three-year rolling rain average (current year plus two previous year's precipitation) was between 40 and 60 cm relative to rain greater than 100 cm. The results suggest that features detected by RS techniques combined with climatic variables can be used to determine the risk of AVL in northeastern Brazil.

Genetic analysis of multicase families of visceral leishmaniasis in northeastern Brazil: no major role for class II or class III regions of HLA.

Familial aggregation, high relative risk to siblings, and segregation analysis, suggest genetic control of visceral leishmaniasis in Brazil. Class II gene effects in mice, and high circulating tumour necrosis factor alpha in humans, provide reasons to target HLA. Fifteen polymorphic markers across 1.03 Mb (DQB1 to TNFa) were genotyped (87 multicase families; 638 individuals). Model-based parametric analyses using single-point combined segregation and linkage in COMDS, or multi-point linkage in ALLEGRO, failed to detect linkage. Model-free nonparametric affected sibling pair (SPLINK) or NPL(all) score (ALLEGRO) analyses also failed to detect linkage. Information content mapping confirmed sufficient marker information to detect linkage. Analysis of simulated data sets demonstrated that these families had 100% power to detect NPL(all) scores of 5 to 6 (>LOD4; P < 0.00001) over the range (7% to 61%) of age-related penetrances for a disease susceptibility gene. The extended transmission disequilibrium test (TDT) showed no consistent allelic associations between disease and the 15 loci. TDT also failed to detect significant associations between extended haplotypes and disease, consistent with failure to detect significant linkage disequilibrium across the region. Linkage disequilibrium between adjacent groups of markers (HLADQ/DR; 82-1/82-3/-238bpTNFA; LTA/62/TNFa) was not accompanied by significant global haplotype TDT associations with disease. The data suggest that class II/III regions of HLA do not contain major disease gene(s) for visceral leishmaniasis in Brazil.

Genetic epidemiology of visceral leishmaniasis in northeastern Brazil

Familial clustering of disease, racial differences in asymptomatic:disease ratios, and studies of mice all point to a genetic component for disease susceptibility in visceral leishmaniasis. Analysis of 87 multi-case pedigrees (824 individuals; 138 nuclear families) from a region of northeastern Brazil endemic for Leishmania chagasi demonstrates a high relative risk ratio (lambda(2S) = 34) to further siblings of affected sibling pairs. Complex segregation analysis using POINTER and COMDS show that all single locus models, as well as polygenic and multifactorial models, provide a significantly (P < 0.001) better fit to the data than a sporadic model. Of the genetic models, the general single locus model was not significantly different from additive or dominant single locus models, all of which gave a gene frequency for the putative disease susceptibility allele of approximately 0.002. The general single locus model was strongly favored (P < 0.001) over a recessive single gene model. Using POINTER, polygenic and multifactorial models were clearly rejected (P < 0.001 in all cases) in favor of the general single locus model. Using COMDS, the analysis was extended to consider two locus models. Results under a general two-locus model did not differ significantly from the dominant, additive, or general single locus models. Under this model, one locus was estimated at a gene frequency of 0.0017, i.e., in the same range as the disease susceptibility locus for the most favored single gene models, with the second locus at a much lower frequency of 0.0002. Hence, the data support the hypothesis that a single major gene may be important in determining disease susceptibility in this population. To identify the gene(s) involved, a genome scan with replication using two subsets of these larger pedigrees with power to detect linkage is in progress.

Genetics of host resistance and susceptibility to intramacrophage pathogens: a study of multicase families of tuberculosis, leprosy and leishmaniasis in north-eastern Brazil

Genetic analysis of disease phenotypes segregating in recombinant inbred, congenic and recombinant haplotype mouse strains permitted us to effectively “scan” the murine genome for genes controlling resistance and susceptibility to leishmanial infections. Five major regions were implicated which, because they show conserved synteny with regions of the human genome, immediately provide candidate gene regions for human disease susceptibility genes. A common intramacrophage niche for leishmanial and mycobacterial pathogens, and a similar spectrum of immune response and disease phenotypes, also led to the prediction that the same genes/candidate gene regions might be responsible for genetic susceptibility to mycobacterial infections such as leprosy and tuberculosis. Indeed, one of the murine genes ( Nramp 1) was identified for its role in controlling a range of intramacrophage pathogens, including leishmanial, salmonella and mycobacterial infections. In recent studies, multicase families of visceral leishmaniasis, tuberculosis and leprosy, from north-eastern Brazil have been analysed to determine the role of these candidate genes/regions in humans. Complex segregation analysis provides evidence for one or two major genes controlling susceptibility to these diseases in this population. Family-based linkage analyses (e.g., combined segregation and linkage analysis; sib-pair analyses) and transmission disequilibrium testing have been used to examine the role of four regions in disease susceptibility and/or immune response phenotypes. Results to date demonstrate: (1) the major histocompatibility complex (MHC: H-2 in mouse, HLA in humans: mouse chromosome 17/human 6p; candidates class II and class III including tumour necrosis factor α β genes) shows both linkage to, and allelic association with, leprosy per se, but is only weakly associated with visceral leishmaniasis and shows neither linkage to, nor allelic association with, tuberculosis; (2) no evidence for linkage between NRAMP1, the positionally cloned candidate for the murine macrophage resistance gene Ity/Lsh/Bcg (mouse chromosome 1/human 2q35), and susceptibility to tuberculosis or visceral leishmaniasis; (3) the region of human chromosome 17q (candidates NOS2A, SCYA2-5) homologous with distal mouse chromosome 11 is linked to tuberculosis susceptibility; and (4) the “T helper 2” cytokine gene cluster (proximal murine chromosome 11/human 5p; candidates IL4, IL5, IL9, IRF1, CD14) is not linked to human disease susceptibility for any of the three infections, but shows linkage to and highly significant allelic association with ability to mount an immune response to mycobacterial antigens. The demonstration of an allelic association between IL4 and immune response to mycobacterial antigen may provide a genetic explanation for the inverse association recently demonstrated between delayed hypersensitivity T helper 1 responses to mycobacterial antigen and atopic disorder in Japanese children. These studies demonstrate that the “mouse-to-human” strategy, refined by our knowledge of the human immune response to infection, can lead to the identification of important candidate gene regions in humans.

An urban outbreak of visceral leishmaniasis in Natal, Brazil

The epidemiological pattern of visceral leishmaniasis in north-eastern Brazil is changing. The disease was typically seen in rural, endemic areas, but is now occurring as an epidemic in the city of Natal where 316 cases have been reported since 1989; 49% were in children less than 5 years of age. The principle clinical and laboratory findings were weight loss, fever, hepato-splenomegaly, anaemia, leucopenia and hypergammaglobulinaemia. Elevated transaminases and hyperbilirubinaemia were also observed. The diagnosis was confirmed in 87% of cases by identifying amastigotes in aspirates from bone marrow or spleen. Five isolates were identified as Leishmania (L.) chagasi by isoenzyme analysis. The mortality rate was 9%; all deaths occurred during the first week in hospital. One person had concurrent human immunodeficiency virus infection. Among 210 household contacts and neighbours of patients from the endemic area examined for evidence of L. (L.) chagasi infection, 6 additional cases of visceral leishmaniasis were diagnosed. Thirtyeight percent of house-mates and neighbours gave a positive Montenegro skin test reaction, indicating prior subclinical infection.

The relationship of American visceral leishmaniasis to ABO blood group type.

It has been hypothesized that the Leishmania use a system of camouflage or mimicry of human ABO blood group antigens to evade host defense mechanisms. In order to test this hypothesis, the distribution of ABO blood groups among healthy control donors and among patients with visceral leishmaniasis in northeastern Brazil was compared. No significant differences were found between patients with American visceral leishmaniasis and controls, indicating that ABO blood group type is not an important determinant in the development of clinically apparent visceral leishmaniasis in that area. The findings raise doubt about the validity of the original hypothesis.