Lupoid leishmaniasis among the known cases of cutaneous leishmaniasis in Herat Province, western Afghanistan

Unusual Observations in Leishmaniasis-An Overview

Leishmaniasis significantly affects the population of the tropics and subtropics. Clinical features and infective species of Leishmania are the primary factors driving the direction of diagnosis. The rise in incidences of atypical presentations present a challenge in patient treatment. Knowledge of unusual/rare presentations can aid in having a broader perspective for including the different aspects during the examination and thus avoid misdiagnosis. A comprehensive literature survey was performed to present the array of atypical presentations confounding clinicians which have been seen in leishmaniasis. Case reports of unusual findings based on the localizations and morphology of lesions and infective species and the predominant geographical sites over almost five decades highlight such presentations in the population. Information regarding the clinical features recorded in the patient and the chosen treatment was extracted to put forward the preferred drug regimen in such cases. This comprehensive review presents various unusual observations seen in visceral leishmaniasis, post-kala-azar dermal leishmaniasis, cutaneous leishmaniasis, and mucocutaneous leishmaniasis. It highlights the need to consider such features in association with differential diagnosis to facilitate proper treatment of the patient.

Atypical manifestations of cutaneous leishmaniasis in a boy from Afghanistan

Cutaneous leishmaniasis is one of the most common forms of leishmaniasis in Afghanistan, which is caused by different Leishmania species that are transmitted to humans by sandflies. Its clinical manifestations are very diverse and depend on a variety of parasite and host factors.

Atypical and unusual morphological variants of cutaneous leishmaniasis

OBJECTIVE

Cutaneous leishmaniasis (CL) is a skin disease characterised by prolonged nodulo-ulcerative lesions of the skin that heals with atrophic scar. Clinical features of CL vary depending on the type of parasite and host immune resistance. The aim of this study was to investigate the clinical features of atypical and unusual morphological variants of CL patients diagnosed in our clinic.

MATERIALS AND METHODS

In this prospective study, 27 CL patients with atypical clinical features among 486 patients admitted to our clinic between July 2018 and September 2019 and diagnosed as CL by slit-skin smear examination or histopathological examination were included.

RESULTS

Of 27 patients, 15 (55.5%) were male and 12 (44.5%) were female. The mean age of the patients was 25.8 ± 7.62 years. Seven (25.9%) patients had lupoid lesions, five (18.6%) patients had eczematoid lesions, four (14.8%) patients had lip lesions, three (11.1%) patients had erysipelas-like lesions, two (7.4%) patients had eyelid lesions, two (7.4%) patients had sporotrichoid lesions, two (7.4%) patients had verrucous lesions, one (3.7%) patient had psoriasiform lesion and one (3.7%) patient had paronychial lesion.

CONCLUSION

In conclusion, rare clinical forms of CL are presented in this study. It should be kept in mind that CL may have very different clinical features and should be considered in the differential diagnosis of eczema, psoriasis, erysipelas, sporotrichosis, paronychia and verrucous lesions.

Phylogenetic position of Leishmania tropica isolates from an old endemic focus in south-eastern Iran; relying on atypical cutaneous leishmaniasis

Cutaneous leishmaniasis (CL) is a major health problem in Iran, with a heavy burden on human health and society. There is little knowledge about the molecular epidemiology of the disease, as well as phylogenetic relationship of causative agents in south-eastern Iran. The aim of the present study was to investigate the molecular aspects of CL, especially atypical CL in the Bam district, Kerman province, south-eastern Iran, as an endemic region of CL in Iran. The smears were collected from lesion samples of 353 patients clinically suspected to CL, who attended local health centres in the Bam district during 2016-2017. Direct smears were examined for Leishmania parasites using the Giemsa staining technique. Amplification of kinetoplast DNA (kDNA) and the ribosomal internal transcribed spacer 1(ITS-1) gene were carried out using polymerase chain reaction (PCR). Then, the ITS1-PCR products were sequenced for phylogenetic analysis. Overall, 278 cases were confirmed as CL by microscopic examination of Giemsa-stained slides. Clinical presentation of the lesions was basically of two types: (a) typical lesions and (b) atypical including lupoid ulcers, sporotrichoid, nodular and exudative lesions. The PCR assay on all specimens of skin lesions proved L. tropica as the main pathogenic agent. Phylogenic analysis revealed high similarity among isolates from the Bam district in the south-east with isolates from Birjand in eastern Iran, as well as with isolates from Herat province in western Afghanistan. The study provided valuable information concerning the genetic diversity of the parasite as one of the factors influencing the clinical manifestations in CL in south-eastern Iran, which could be the basis for planning future control strategies.

A successful treatment of severe lupoid cutaneous leishmaniasis in an elderly man: a case report

Lupoid cutaneous leishmaniasis (LCL) is a rare, atypical presentation of cutaneous leishmaniasis (CL). In this report, the authors present the case of a severe LCL in an elderly patient who presented to our dermatology department with severe, painful ulcerated lesion on his midface with cosmetic deformity to his nose. He had a history of CL 3 years ago at the same place. Histopathologic examination showed epidermal and dermal changes with chronic inflammatory infiltrate and no leishmaniasis bodies were detected. He was admitted and treated with systemic glucantime (60 mg/kg) for a month followed by hydroxychloroquine (200 mg twice a day) for another month with favorable outcome. Countries with endemic CL should consider LCL in patients with a history of leishmaniasis and a similar clinical presentation, especially that it could be misdiagnosed with other granulomatous cutaneous conditions, thus leading to cosmetic deformities that can be avoided with early adequate treatment.

Modelling the number of dermal lesions in anthroponotic cutaneous leishmaniasis and its associated factors in Herat province, western Afghanistan, during 2012-2013

Cutaneous leishmaniasis (CL), caused by Leishmania tropica, is the main causative agent of CL in the Herat province, western Afghanistan. In CL patients, one of the most important indicators for reducing the amount of body damage and the choice of treatment is the number of dermal lesions, but there is no strong evidence in this regard. Therefore, using count regression models, the main objective of this historical cohort study was to identify the distribution of the number of dermal lesions and determine the associated factors among CL patients referring to leishmaniasis reference laboratory in Herat province, from January 2012 to December 2013. In a total of 4,127 clinically suspected CL cases, 50.20% were female and 49.80% male. Based on the results of ZINB model, which is the best model suggested by goodness-of-fit criteria, age variables (IRR = 1.007), duration of lesion (6-12 weeks compared to < 6 weeks with IRR = 1.36 and >12 weeks with IRR = 1.39 compared to <6 weeks), type of lesion(both nodule and ulcer compared to papule with IRR = 2.03), location of lesion (trunk with IRR = 1.90, upper with IRR = 1.66, lower with IRR = 1.61 and mix with IRR = 10.35 compared to head/neck/ears) and type of lesion (ulcer compared to papule with IRR = 0.50, nodule and lupoid, respectively, as IRR = 0.72 and IRR = 0.51 compared to papule) had a significant effect on the mean number of dermal lesions (p < .05). Also, our results showed that among four models used, the ZINB model represented a better performance to determine the associated probable factors about the number of dermal lesions in ACL patients. Moreover, there was a direct association between age and number of dermal lesions; in addition, duration of lesion, type of lesion and location of lesion had a significant effect on the number of dermal lesions. Therefore, a comprehensive planning is necessary for controlling and reducing the number of dermal lesions.

Salvage therapy with Sodium chlorosum (formerly DAC N-055) for cases of refractory lupoid cutaneous leishmaniasis: results from a compassionate use study with 0.09% Sodium chlorosum in amphiphilic basic cream

Background

Lupoid cutaneous leishmaniasis (LCL) is known as a rare but serious complication of anthroponotic cutaneous leishmaniasis (ACL) resistant to conventional treatments. Sodium chlorosum, a pro-oxidative preparation of pharmaceutical sodium chlorite (NaClO₂), has been successfully used for the treatment of Old World cutaneous leishmaniasis lesions (OWCL) and of some LCL cases in Afghanistan. This clinical trial study aimed to evaluate the effect of a last resort therapy with topical 0.09% sodium chlorosum on LCL in Iran.

Methods

Twenty Iranian patients (12 women and 8 men) with LCL refractory to treatment were included in this salvage study. A magistral preparation of sodium chlorosum (10 mM NaClO₂ in amphiphilic basic cream) was applied twice daily to the lesions for 6 weeks and continued up to 12 weeks in patients who showed a clinical response within the first 6 weeks. Responders were followed up for a maximum of 1 year. Lesions were photographed during weekly visits. Disappearance of erythema and indurated lesions were rated as complete clinical response.

Results

Patients with a mean age of 28.6 (±24.3) and with an ACL proven lesion history of 3.8 (±1.4) years were treated for an average of 7.9 (±1.8) weeks. At the end of the treatment period (12th week), a complete response was observed in 9 of 20 patients (45%). During the one-year follow-up period, LCL lesions recurred in 4 of these 9 patients (with one patient showing only a tiny lesion) and one case lost to follow up whereas the other four remained completely lesion-free. Mild temporary side-effects such as erythema and itching were seen in 4 of 20 patients (20%).

Conclusions

Topical sodium chlorosum showed promising therapeutic results and can be considered as safe, painless, and relatively effective treatment for LCL, an ethical prerequisite for a two-armed controlled trial.

Trial registration

This study was registered in Iranian registry of clinical trials on 2019-02-02 with registration number IRCT20190114042356N1.

Evaluation of IL-12RB1, IL-12B, CXCR-3 and IL-17a expression in cases affected by a non-healing form of cutaneous leishmaniasis: an observational study design

INTRODUCTION

Seldom cutaneous leishmaniasis (CL) may present as a lasting and active lesion(s), known as a non-healing form of CL (NHCL). Non-functional type 1 T helper (Th1) cells are assumed the most important factor in the outcome of the disease. The present study aims to assess some molecular defects that potentially contribute to Th1 impairment in NHCL.

METHODS AND ANALYSIS

This prospective observational study will be implemented among five groups. The first and second groups comprise patients afflicted with non-healing and healing forms of CL, respectively. The third group consists of those recovered participants who have scars as a result of CL. Those participants who have never lived or travelled to endemic areas of leishmaniasis will comprise the fourth group. The fifth group comprises participants living in hyperendemic areas for leishmaniasis, although none of them have been afflicted by CL. The aim is to recruit 10 NHCL cases and 30 participants in each of the other groups. A leishmanin skin test (LST) will be performed to assess in vivo immunity against the Leishmania infection. The cytokine profile (interleukin (IL)-12p70, interferon (IFN)-γ, C-X-C motif chemokine ligand (CXCL)-11 and IL-17a) of the isolated peripheral blood mononuclear cells (PBMCs) will be evaluated through ELISA. Real-time PCR will determine the C-X-C motif chemokine receptor (CXCR)-3 and IL-17a gene expression and expression of IL-12Rβ1 will be assessed by flow cytometry. Furthermore, IL-12B and IL-12RB1 mutation analysis will be performed.

DISCUSSION

It is anticipated that the outcome of the current study will identify IL-12B and IL-12RB1 mutations, which lead to persistent lesions of CL. Furthermore, our expected results will reveal an association between NHCL and pro-inflammatory cytokines (IL-12p70, IFN-γ IL-17a and CXCL-11), as well as CXCR-3 expression.

ETHICS AND DISSEMINATION

This study has been approved by a local ethical committee. The final results will be disseminated through peer-reviewed journals and scientific conferences.