Volume 100, Issue 2
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Current diagnostic tests for visceral leishmaniasis (VL) are either not adapted for use in resource-poor settings or are insufficiently accurate in Eastern Africa. Only the direct agglutination test (DAT), based on whole promastigotes, is highly reliable in all endemic regions, but its implementation is hampered by the need for a cold chain, minimal laboratory conditions, and long incubation times. Integrating the DAT antigen(s) in an immunochromatographic rapid diagnostic test (RDT) would overcome these disadvantages. Unfortunately, the identity of the DAT antigen(s) involved in the agglutination reaction is unknown. For this study, we reviewed all publications that might shed some light on this issue. We conclude that the DAT antigen is a mixture of -specific epitopes of protein, carbohydrate, and lipid nature. To develop an accurate RDT for VL diagnosis in Eastern Africa, we suggest to complement the classical protein antigen discovery with approaches to identify carbohydrate and lipid epitopes.

[open-access] This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


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  1. Chappuis F, Rijal S, Soto A, Menten J, Boelaert M, , 2006. A meta-analysis of the diagnostic performance of the direct agglutination test and rK39 dipstick for visceral leishmaniasis. BMJ 333: 723726. [Google Scholar]
  2. El Harith AE, Kolk AH, Kager PA, Leeuwenburg J, Muigai R, Kiugu S, Kiugu S, Laarman JJ, , 1986. A simple and economical direct agglutination test for serodiagnosis and sero-epidemiological studies of visceral leishmaniasis. Trans R Soc Trop Med Hyg 80: 583586. [Google Scholar]
  3. Allain DS, Kagan IG, , 1975. A direct agglutination test for leishmaniasis. Am J Trop Med Hyg 24: 232236. [Google Scholar]
  4. Meredith SE, Kroon NC, Sondorp E, Seaman J, Goris MG, van Ingen CW, Oosting H, Schoone GJ, Terpstra WJ, Oskam L, , 1995. Leish-KIT, a stable direct agglutination test based on freeze-dried antigen for serodiagnosis of visceral leishmaniasis. J Clin Microbiol 33: 17421745. [Google Scholar]
  5. Jacquet D, Boelaert M, Seaman J, Rijal S, Sundar S, Menten J, Magnus E, , 2006. Comparative evaluation of freeze-dried and liquid antigens in the direct agglutination test for serodiagnosis of visceral leishmaniasis (ITMA-DAT/VL). Trop Med Int Health 11: 17771784. [Google Scholar]
  6. Zijlstra EE, Osman OF, Hofland HW, Oskam L, Ghalib HW, el-Hassan AM, Kager PA, Meredith SE, , 1997. The direct agglutination test for diagnosis of visceral leishmaniasis under field conditions in Sudan: comparison of aqueous and freeze-dried antigens. Trans R Soc Trop Med Hyg 91: 671673. [Google Scholar]
  7. Adams ER, Jacquet D, Schoone G, Gidwani K, Boelaert M, Cunningham J, , 2012. Leishmaniasis direct agglutination test: using pictorials as training materials to reduce inter-reader variability and improve accuracy. PLoS Negl Trop Dis 6: e1946. [Google Scholar]
  8. Boelaert M, 1999. Multi-centre evaluation of repeatability and reproducibility of the direct agglutination test for visceral leishmaniasis. Trop Med Int Health 4: 3137. [Google Scholar]
  9. Boelaert M, 2008. Diagnostic tests for kala-azar: a multi-centre study of the freeze-dried DAT, rK39 strip test and KAtex in east Africa and the Indian subcontinent. Trans R Soc Trop Med Hyg 102: 3240. [Google Scholar]
  10. Mabey D, Peeling RW, Ustianowski A, Perkins MD, , 2004. Diagnostics for the developing world. Nat Rev Microbiol 2: 231240. [Google Scholar]
  11. Sundar S, Reed SG, Singh VP, Kumar PC, Murray HW, , 1998. Rapid accurate field diagnosis of Indian visceral leishmaniasis. Lancet 351: 563565. [Google Scholar]
  12. Boelaert M, Verdonck K, Menten J, Sunyoto T, van Griensven J, Chappuis F, Rijal S, , 2014. Rapid tests for the diagnosis of visceral leishmaniasis in patients with suspected disease. Cochrane Database Syst Rev 6: 1119. [Google Scholar]
  13. Burns JM, Shreffler WG, Benson DR, Ghalib HW, Badaro R, Reed SG, , 1993. Molecular characterization of a kinesin-related antigen of Leishmania chagasi that detects specific antibody in African and American visceral leishmaniasis. Proc Natl Acad Sci U S A 90: 775779. [Google Scholar]
  14. Pattabhi S, 2010. Design, development and evaluation of rK28-based point-of-care tests for improving rapid diagnosis of visceral leishmaniasis. PLoS Negl Trop Dis 4: e822. [Google Scholar]
  15. Bezuneh A, 2014. Comparison of point-of-care tests for the rapid diagnosis of visceral leishmaniasis in east African patients. Am J Trop Med Hyg 91: 11091115. [Google Scholar]
  16. Mukhtar M, Abdoun A, Ahmed AE, Ghalib H, Reed SG, Boelaert M, Menten J, Khair MM, Howard RF, , 2015. Diagnostic accuracy of rK28-based immunochromatographic rapid diagnostic tests for visceral leishmaniasis: a prospective clinical cohort study in Sudan. Trans R Soc Trop Med Hyg 109: 594600. [Google Scholar]
  17. Greval SDS, Napier LE, Gupta PC, , 1939. Serological reactions in kala-azar: complement-fixation, false Wassermann reaction, and high anti-complementary titre. Indian J Med 27: 181190. [Google Scholar]
  18. Napier LE, , 1922. A new serum test for kala-azar. Indian J Med Res 136: 830846. [Google Scholar]
  19. Boelaert M, 2004. A comparative study of the effectiveness of diagnostic tests for visceral leishmaniasis. Am J Trop Med Hyg 70: 7277. [Google Scholar]
  20. Hommel M, Attar Z, Fargeas C, Dourado C, Monsigny M, Mayer R, Chance ML, , 1997. The direct agglutination test: a non-specific test specific for the diagnosis of visceral leishmaniasis? Ann Trop Med Parasitol 91: 795802. [Google Scholar]
  21. Galvão-Castro B, Sá Ferreira JA, Marzochi KF, Marzochi MC, Coutinho SG, Lambert PH, , 1984. Polyclonal B cell activation, circulating immune complexes and autoimmunity in human American visceral leishmaniasis. Clin Exp Immunol 56: 5866. [Google Scholar]
  22. Attar ZJ, , 1997. Studies on the Immunodiagnosis of Visceral Leishmaniasis. PhD Thesis, University of Liverpool. ISNI: 0000 0001 3432 3965. [Google Scholar]
  23. Abass E, Mansour D, el Mutasim M, Hussein M, El Harith A, , 2006. Beta-mercaptoethanol-modified ELISA for diagnosis of visceral leishmaniasis. J Med Microbiol 55: 11931196. [Google Scholar]
  24. Argov S, Jaffe CL, Krupp M, Slor H, Shoenfeld Y, , 1989. Autoantibody production by patients infected with Leishmania. Clin Exp Immunol 76: 190197. [Google Scholar]
  25. Lakhal S, Benabid M, Sghaier IB, Bettaieb J, Bouratbine A, Galai Y, , 2015. The sera from adult patients with suggestive signs of autoimmune diseases present antinuclear autoantibodies that cross-react with Leishmania infantum conserved proteins: crude Leishmania histone and soluble Leishmania antigens [corrected]. Immunol Res 61: 154159. [Google Scholar]
  26. Andrade CR, Silva OA, Andrade PP, Kolk AH, Harith AE, , 1987. A direct agglutination test discriminative toward Chagas’ disease for the diagnosis of visceral leishmaniasis in Brazil: preliminary results. Ann Inst Pasteur Immunol 138: 457459. [Google Scholar]
  27. Naderer T, Vince JE, McConville MJ, , 2004. Surface determinants of Leishmania parasites and their role in infectivity in the mammalian host. Curr Mol Med 4: 649665. [Google Scholar]
  28. Turco SJ, , 1988. The lipophosphoglycan of Leishmania. Parasitol Today Pers Ed 4: 255257. [Google Scholar]
  29. Sacks DL, , 2001. Leishmania-sand fly interactions controlling species-specific vector competence. Cell Microbiol 3: 189196. [Google Scholar]
  30. Elhay MJ, McConville MJ, Handman E, , 1988. Immunochemical characterization of a glyco-inositol-phospholipid membrane antigen of Leishmania major. J Immunol 141: 13261331. [Google Scholar]
  31. Maalej IA, Chenik M, Louzir H, Ben Salah A, Bahloul C, Amri F, Dellagi K, , 2003. Comparative evaluation of ELISAs based on ten recombinant or purified Leishmania antigens for the serodiagnosis of Mediterranean visceral leishmaniasis. Am J Trop Med Hyg 68: 312320. [Google Scholar]
  32. Karp CL, Turco SJ, Sacks DL, , 1991. Lipophosphoglycan masks recognition of the Leishmania donovani promastigote surface by human kala-azar serum. J Immunol 147: 680684. [Google Scholar]
  33. Grubhoffer L, Hypsa V, Volf P, , 1997. Lectins (hemagglutinins) in the gut of the important disease vectors. Parasite 4: 203216. [Google Scholar]
  34. Andrade CR, Andrade PP, Wright EP, , 1988. Leishmania donovani donovani antigens recognized by kala-azar patient sera and identification of cross-reacting antigens to Chagas’ disease. Braz J Med Biol Res 21: 511515. [Google Scholar]
  35. Nogueira N, , 1983. Host and parasite factors affecting the invasion of mononuclear phagocytes by Trypanosoma cruzi. Ciba Found Symp 99: 5273. [Google Scholar]
  36. Santos MAM, de Andrade PP, de Andrade CR, Padovan PA, Souza W, , 1991. Effect of trypsin and 2-mercaptoethanol on the exposure of sugar residues on the surface of Leishmania donovani chagasi. Parasitol Res 77: 553557. [Google Scholar]
  37. Andrade PP, Schottelius J, Andrade CR, , 1988. An enzyme-linked lectin assay for the study of lectin receptors of Leishmania. Braz J Med Biol Res 21: 517521. [Google Scholar]
  38. El Harith A, Chowdhury S, al-Masum A, Semião-Santos S, Karim E, el-Safi S, Haque I, , 1995. Evaluation of cleaving agents other than trypsin in direct agglutination test for further improving diagnosis of visceral leishmaniasis. J Clin Microbiol 33: 19841988. [Google Scholar]
  39. Lepay DA, Nogueira N, Cohn Z, , 1983. Surface antigens of Leishmania donovani promastigotes. J Exp Med 157: 15621572. [Google Scholar]
  40. Shreffler WG, Burns JM, Badaró R, Ghalib HW, Button LL, McMaster WR, Reed SG, , 1993. Antibody responses of visceral leishmaniasis patients to gp63, a major surface glycoprotein of Leishmania species. J Infect Dis 167: 426430. [Google Scholar]
  41. Abass E, Mahamoud A, Mansour D, Mohebali M, El Harith A, , 2011. Validation of a β-ME ELISA for detection of anti Leishmania donovani antibodies in eastern Sudan. Iran J Immunol 8: 150158. [Google Scholar]
  42. Vallur AC, Reinhart C, Mohamath R, Goto Y, Ghosh P, Mondal D, Duthie MS, Reed SG, , 2016. Accurate serodetection of asymptomatic Leishmania donovani infection by use of defined antigens. J Clin Microbiol 54: 10251030. [Google Scholar]
  43. Slutzky GM, Londner MV, Greenblatt CL, , 1985. Lipid and lipopolysaccharide-like antigens of Leishmania promastigotes. J Protozool 32: 347352. [Google Scholar]
  44. Bhattacharyya T, Boelaert M, Miles MA, , 2013. Comparison of visceral leishmaniasis diagnostic antigens in African and Asian Leishmania donovani reveals extensive diversity and region-specific polymorphisms. PLoS Negl Trop Dis 7: e2057. [Google Scholar]
  45. Downing T, 2012. Genome-wide SNP and microsatellite variation illuminate population-level epidemiology in the Leishmania donovani species complex. Infect Genet Evol 12: 149159. [Google Scholar]
  46. Van Nieuwenhove L, Büscher P, Balharbi F, Humbert M, Dieltjens T, Guisez Y, Lejon V, , 2012. Identification of mimotopes with diagnostic potential for Trypanosoma brucei gambiense variant surface glycoproteins using human antibody fractions. PLoS Negl Trop Dis 6: e1682. [Google Scholar]
  47. Umair S, Deng Q, Roberts JM, Shaw RJ, Sutherland IA, Pernthaner A, , 2016. Identification of peptide mimics of a glycan epitope on the surface of parasitic nematode larvae. PLoS One 11: e0162016. [Google Scholar]
  48. Salles BCS, 2017. Leishmania infantum mimotopes and a phage-ELISA assay as tools for a sensitive and specific serodiagnosis of human visceral leishmaniasis. Diagn Microbiol Infect Dis 87: 219225. [Google Scholar]
  49. Leung NY, Wai CY, Ho MH, Liu R, Lam KS, Wang JJ, Shu SA, Chu KH, Leung PS, , 2017. Screening and identification of mimotopes of the major shrimp allergen tropomyosin using one-bead-one-compound peptide libraries. Cell Mol Immunol 14: 308318. [Google Scholar]
  50. Blixt O, Hoffmann J, Svenson S, Norberg T, , 2008. Pathogen specific carbohydrate antigen microarrays: a chip for detection of Salmonella O-antigen specific antibodies. Glycoconj J 25: 2736. [Google Scholar]
  51. Elshafie AI, Mullazehi M, Rönnelid J, , 2016. General false positive ELISA reactions in visceral leishmaniasis. Implications for the use of enzyme immunoassay analyses in tropical Africa. J Immunol Methods 431: 6671. [Google Scholar]

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  • Received : 07 Sep 2018
  • Accepted : 02 Nov 2018
  • Published online : 17 Dec 2018

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