Localized lymphadenopathy due to leishmanial infection

Non-Endemic Leishmaniases Reported Globally in Humans between 2000 and 2021—A Comprehensive Review

Leishmaniases are human and animal parasitic diseases transmitted by phlebotomine sand flies. Globalization is an important driver of the burden and in the current dynamics of these diseases. A systematic review of articles published between 2000 and 2021 was conducted using the PubMed search engine to identify the epidemiology and clinical management of imported human leishmaniases as a fundamental step to better manage individual cases and traveler and migrant health from a global perspective. A total of 275 articles were selected, representing 10,341 human imported cases. Identified drivers of changing patterns in epidemiology include conflict and war, as well as host factors, such as immunosuppression, natural and iatrogenic. Leishmania species diversity associated with different clinical presentations implies diagnostic and treatment strategies often complex to select and apply, especially in non-endemic settings. Thus, diagnostic and management algorithms for medical clinical decision support are proposed. Increased surveillance of non-endemic cases, whether in vulnerable populations such as refugees/migrants and immunocompromised individuals or travelers, could improve individual health and mitigate the public health risk of introducing Leishmania species into new areas.

Atypical presentation in adults in the largest community outbreak of leishmaniasis in Europe (Fuenlabrada, Spain)

Since 2009, the largest reported outbreak of leishmaniasis by Leishmania infantum in Europe was reported in Fuenlabrada, Spain. In our hospital, 90 adults with localized leishmanial lymphadenopathy (LLL) or visceral leishmaniasis (VL) were treated during this outbreak; 72% were men, and the mean age was 46.2 years (range 15-95 years). A total of 17 cases (19%) were LLL, an atypical form with isolated lymphadenopathies without other symptoms. All LLL cases occurred in immunocompetent subjects, and only one subject (6%) was a native of sub-Saharan Africa. Diagnosis was performed by fine needle aspiration cytology of the lymphadenopathy. Serology was negative in 38%. LLL outcomes at 6 months were benign, even with doses of liposomal amphotericin B that were often lower (10 mg/kg) than those recommended for VL in Mediterranean areas. A total of 73 subjects (81%) presented with typical VL; 66% of this group were immunocompetent, and 50% of those who were immunocompetent were descendants of natives of sub-Saharan Africa. The rK39 test and polymerase chain reaction were the most useful tests for confirmation of the diagnosis. An initial response to treatment was observed in 99% of cases, and relapses occurred in 14% of cases. Leishmaniasis should be included in the differential diagnosis of isolated lymphadenopathies in endemic areas. LLL could be considered a more benign entity, one different than VL, and less aggressive management should be studied in future investigations.

Atypical manifestations of visceral leishmaniasis in patients with HIV in north Ethiopia: a gap in guidelines for the management of opportunistic infections in resource poor settings

In regions where it is endemic, visceral leishmaniasis is an important opportunistic infectious disease in people living with HIV. Typically, clinical presentation of visceral leishmaniasis includes chronic fever, hepatosplenomegaly, and weight loss. In Leishmania infantum endemic regions in Europe, atypical visceral leishmaniasis presentations have been well documented, with almost every possible organ involved. However, such reports are rare in Leishmania donovani endemic regions such as east Africa. In this Personal View, we describe the various atypical disease presentations in patients screened as part of an HIV and visceral leishmaniasis clinical trial in north Ethiopia, where up to 40% of patients with visceral leishmaniasis are co-infected with HIV. Atypical presentations such as these are not covered in clinical guidelines used in these settings. Apart from the lack of diagnostic facilities, this gap contributes to the underdiagnosis of atypical visceral leishmaniasis, with associated morbidity and mortality. Involvement of clinicians experienced with the management of HIV and visceral leishmaniasis co-infection in the development of HIV clinical guidelines in affected regions is warranted.

Outbreak of cutaneous leishmaniasis in Fuenlabrada, Madrid

BACKGROUND

Leishmaniasis, an endemic infection in Spain, is caused by protozoan parasites of the Leishmania genus. Between 2010 and 2012, there was an outbreak of cutaneous and visceral leishmaniasis in Fuenlabrada, Madrid.

OBJECTIVES

To describe the cases of cutaneous leishmaniasis diagnosed over a 17-month period at the dermatology department of Hospital de Fuenlabrada.

MATERIAL AND METHODS

We analyzed the epidemiological, clinical, histological, and microbiological features of each case and also evaluated the treatments administered and outcomes.

RESULTS

We studied 149 cases. The incidence of cutaneous leishmaniasis showed a peak in the age range between 46 and 60 years and was similar in men and women. At the time of consultation, the lesions had been present for between 2 and 6 months in the majority of patients. The most common clinical presentation was with erythematous plaques and papules without crusts (52% of cases). Lesions were most often located in sun-exposed areas and were multiple in 57% of patients. In 67% of cases, the histological study showed non-necrotizing granulomatous dermatitis with no evidence of parasites using conventional staining methods. Diagnosis was confirmed by polymerase chain reaction (PCR) in 98% of patients. In the remaining cases, the histological study revealed Leishman-Donovan bodies in the skin. Intralesional pentavalent antimonials were the most commonly used drugs (76% of cases) and produced satisfactory results.

CONCLUSIONS

We have presented a large series of cases of cutaneous leishmaniasis diagnosed in the context of an outbreak. Multiple papules were the most common clinical presentation, with histology that showed non-necrotizing granulomatous dermatitis with no evidence of parasites. PCR of skin samples was the test that most frequently provided the diagnosis.

Role of fine-needle aspiration cytology in the prompt diagnosis of recurrence of visceral leishmaniasis presented as isolated cervical leishmanial lymphadenopathy

We report a case of isolated cervical leishmanial lymphadenopathy diagnosed by fine-needle aspiration cytology (FNAC) in apparently cured case of visceral leishmaniasis. A 28-year-old female presented with cervical lymphnode enlargement to surgery outpatient department and was subjected for FNAC. Smear showed numerous Leishmania donovani bodies in the cytoplasm of macrophages and giant cells, and extracellular spaces. She was treated by Amphotericin B for alternate 14 days and the size of the lymphnode regressed. She was found asymptomatic for 1 year of follow-up.

Cutaneous leishmaniasis associated with extensive lymphadenopathy during an epidemic in Ceará State, northeast Brazil

During an epidemic of cutaneous leishmaniais in northeast Brazil a prospective study was conducted in order to assess clinical, parasitological and immunological features of cutaneous leishmaniasis in a representative sample of patients. A general examination was done and demographic and anthropometric data as well as numbers, duration, location, size, consistency and tenderness of enlarged lymph nodes and lesions recorded. Hematologic and biochemical parameters as well as Leishmania-specific antibodies were measured in the blood. Lymph node aspirations were performed to detect Leishmania-specific DNA by PCR. Cellular immunity was assessed by a leishmanin skin test. Ninety-seven patients with cutaneous leishmaniasis presented with a total of 181 lesions and 127 enlarged regional lymph nodes. In 36% the lymph node enlargement had been observed 2 days to 2 months before the development of a lesion. In 59% the lesions were followed by lymphadenopathy by 3 days to 3 months. The skin test was positive in all patients tested. PCR of the lymph node aspirates was positive in 63.2%. No significant correlations were found between positive PCR results, antibody levels or number of lesions. In northeast Brazil cutaneous leishmaniasis due to Leishmania braziliensis is constantly accompanied by an extensive lymphadenopathy. This may help to identify patients when lesions are still small or have not even developed and lymphadenopathy is the only clinical sign.

Leishmaniasis in Germany

In 2000, a reference center was created to systematically record leishmaniases in Germany. We analyzed 58 cases of leishmaniases imported during a 2-year period. These findings will serve as a baseline for the sandfly vector's anticipated northward move because of global warming and as an advisory for immunocompromised persons traveling to leishmaniasis-endemic areas.