Unusual clinical variants of cutaneous leishmaniasis in Pakistan

Many faces of cutaneous leishmaniasis

BACKGROUND

Our objective in this study is to determine the atypical clinical presentations of cutaneous leishmaniasis (CL) patients diagnosed in Şanlıurfa province.

METHODS

This retrospective study included 213 patients with atypical clinical presentations among 1751 patients diagnosed with CL between October 2019 and August 2022 in Şanlıurfa Oriental Boil Diagnosis and Treatment Center located in an endemic region for CL.

RESULTS

We found the prevalence of atypical CL to be 12.1%. The most common atypical lesions were lupoid 21 (9.8%), erysipeloid 16 (7.5%), impetiginous 16 (7.5%), recidivan 15 (7%), eczematous 15 (7%), ecthyma-like 13 (6.1%), pyoderma gangrenous-like 12 (5.6%), and sporotrichoid 12 (5.6%). Other lesions with atypical clinical presentations: chalazion-like, verrucous, dental sinus-like, psoriasiform, zosteriform, lymphoma-like, juvenile xanthogranuloma-like, volcano-like, paronychial, basal cell carcinoma-like, squamous cell carcinoma-like, herpes labialis-like, keratoacanthoma-like, chancriform, annular, lichenoid, mastocitoma-like, keloidal, epidermoid cyst-like, kaposi sarcoma-like, scar leishmaniasis, granulomatous cheilitis-like, mycetoma-like, molluscum contagiosum-like, discoid lupus erythematosus-like, and dermatofibroma-like.

CONCLUSIONS

In addition to the atypical clinical presentations previously reported, we also defined dermatofibroma-like, Kaposi sarcoma-like, dental sinus-like, juvenile xanthogranuloma-like, mastocytoma-like, and epidermoid cyst-like. It should be kept in mind that CL can clinically mimic many infectious, inflammatory, and neoplastic diseases, which should be considered in the differential diagnosis of long-term non-healing lesions, especially in endemic areas. Key message What is already known on this subject:  CL is known as the great imitator disease in dermatology. What this study adds:  In addition to the atypical clinical presentations previously reported, we also defined dermatofibroma-like, Kaposi sarcoma-like, dental sinus-like, juvenile xanthogranuloma-like, mastocytoma-like, and epidermoid cyst-like. How this study might affect research, practice, or policy:  CL can clinically mimic many infectious, inflammatory and neoplastic diseases, which should be considered in the differential diagnosis of long-term non-healing lesions, especially in endemic areas.

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.

Annular infectious dermatoses

Annular configuration is conspicuous in the clinical manifestation of many skin diseases and can be helpful for the diagnosis and differential diagnosis. Variations may include arciform, ring-form, annular, circinate, serpiginous, gyrated, polycyclic, targeted or figurate forms, in different colors, sizes, and numbers, with various textures and surfaces. In infectious dermatoses, the annular reactions can be specific or nonspecific, while the underlying mechanisms remain largely unknown. In the specific reactions caused by direct invasion of the pathogens, the contest between the centrifugal outspread of the infectious agents and the centripetal impedance of the host immune response is supposed to determine the final conformation. Examples include erythema infectiosum, orf, erythema multiforme, and pityriasis rosea of viral origin. Bacterial infections that may display annular lesions include erythrasma, erythema (chronicum) migrans of Lyme borreliosis, secondary syphilis, cutaneous tuberculosis, and leprosy. Superficial mycosis, such as dermatophytosis, candida intertrigo, tinea imbricata, and subcutaneous mycosis, such as chromoblastomycosis, and algae infection protothecosis, are characterized by annular progression of the skin lesions. The creeping serpiginous extension is an alarming sign for the diagnosis of cutaneous larva migrans. A better understanding of the virulence and pathogenicity of the pathogens and the way and type of immune response will help to clarify the pathogenesis.

Erysipeloid cutaneous leishmaniasis: a study of 40 cases of an unusual variant

BACKGROUND

Erysipeloid cutaneous leishmaniasis (ECL) is known as the chronic form of cutaneous leishmaniasis (CL). However, keeping its clinical presentation in view, there is a need to revisit this form of the disease.

AIMS

To describe ECL in view of clinical features and treatment modalities.

METHODS

We include a case series seen in Sfax (Southern Tunisia) from January 2017 to January 2021. All patients clinically suggestive and laboratory confirmed with a diagnosis of CL were registered. Patients of all age groups and of either gender having cutaneous lesions resembling erysipela on the face were included in the study. Different demographic features of the patients and clinical aspects were identified. Descriptive statistics were used for analysis.

RESULTS

Of 1300 registered patients with CL, 40 (3%) were diagnosed as ECL. Ages ranged from 15 to 65 years, and duration of lesions varied from 15 to 180 days. All patients had lesions over the face. Clinically, a painful infiltrated inflammatory placard of the central facial area with a butterfly shape was observed in 14 cases, as well as zones of the cheekbone (11 cases), cheekbone and nose (5 cases), cheekbone and eyelid (8 cases), and cheekbone with ear (2 cases). Several therapeutic methods were prescribed with a sufficient result with no recurrence.

CONCLUSION

ECL is a rare presentation that typically occurs on the face, looking like erysipelas, in patients who are native from an endemic region of CL.

Inflammatory Nasal Swelling due to Leishmania tropica

Since its discovery in the 19th century, cutaneous leishmaniasis has been a major public health problem, especially with the appearance of more and more unusual cases of cutaneous lesions due to this parasite. Indeed, the present study joins the previous studies and describes a typical case of a nasal lesion due to Leishmania infection. This is a 20-year-old young man, with no particular pathological history, from an epidemic focus who presented with inflammatory nasal swelling similar to a mucocutaneous form. However, the X-ray data showed that no lysis of the bones proper to the nose was detected and no damage to the underlying mucosa was observed. Nevertheless, the parasitological diagnosis confirmed the presence of amastigotes, and the results of the molecular study showed that the electrophoretic profile was comparable to that of L. tropica. After diagnosis and confirmation, treatment with meglumine antimonate at the rate of two ampoules/injection (one ampoule = 5 ml) of antimony salt for one month was administered intramuscularly with favorable outcome. Atypical forms of cutaneous leishmaniasis constitute a rare and unusual entity often leading to diagnostic delay. For this, the clinical examination must take into account both exceptional presentations of Leishmania infection, in particular in subjects living or having stayed in an endemic area, in order to ensure appropriate and early treatment.

Acute and chronic paronychia revisited: A narrative review

Paronychia refers to the inflammation of the tissue which immediately surrounds the nail and it can be acute (<6 weeks duration) or chronic (>6 weeks duration). Disruption of the protective barrier between the nail plate and the adjacent nail fold preceded by infectious or noninfectious etiologies results in the development of paronychia. A combination of general protective measures, and medical and/or surgical interventions are required for management. This review explores the pathogenesis, clinical features, differential diagnosis, medical, and surgical management of paronychia. For the purpose of this review, we searched the PubMed, Cochrane, and Scopus databases using the following keywords, titles, and medical subject headings (MeSH): acute paronychia, chronic paronychia, and paronychial surgeries. Relevant review articles, original articles, and case reports/series published till February 2020 were included in this study.

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.

Case Report: Coinfection by Leishmania amazonensis and HIV in a Brazilian Diffuse Cutaneous Leishmaniasis Patient

Diffuse cutaneous leishmaniasis (DCL) is a rare type of leishmaniasis characterized by diffuse skin lesions. In Brazil, Leishmania (L.) amazonensis is the main etiological agent of this clinical form. The state of Maranhão has the highest prevalence of this disease in the country, as well as a high rate of HIV infection. Here, we report the first case of DCL/HIV of Brazil. A 46-year-old man from the Amazonian area of Maranhão state presented atypical lesion in the left upper limb and dissemination of diffuse erythematous nodules over his entire body. Histopathological examination confirmed the presence of intracellular amastigotes of Leishmania, and a polymerase chain reaction and molecular identification by restriction fragment profile identified L. (L.) amazonensis as the causative agent of the disease. The patient was also diagnosed with HIV virus after the leishmaniasis diagnosis. The initial treatments for leishmaniasis were liposomal amphotericin B (AmB-L) (4 mg/kg) for 10 days and prophylactic use of Glucantime^® (10 mg/Sb⁺⁵/kg) for 2 months. After unsuccessful initial treatments, he was treated with a combination of AmB-L (4 mg/kg) alternated with pentamidine (4 mg/kg) for 10 days but failed in the first therapeutic cycle. Subsequently, he had a good response to treatment with pentamidine (4 mg/kg).

Cutaneous leishmaniasis in male schoolchildren in the upper and lower Dir districts of Khyber Pakhtunkhwa, and a review of previous record in Pakistan

Documented reports are limited, showing cutaneous leishmaniasis (CL) as a severe threat to schoolchildren in Pakistan. The present study aimed to investigate the clinico-epidemiology and associated risk factors of CL in local and Afghan male schoolchildren between 6 and 16 years of age. The experimental strategy involved a questionnaire for the collection of information and clinical diagnosis (microscopy and semi-nested PCR) of 113 CL symptomatic schoolchildren out of 8,833 schoolchildren (7,175 local and 1,658 Afghan refugees) studying in nineteen schools of the Upper and Lower Dir Districts, Khyber Pakhtunkhwa, Pakistan. Previous records of CL in Pakistan was studied, and spatial analysis was performed on elevation and agro-ecological maps using Arc-GIS v10.3.1. Active lesions were found predominant (n=113, 1.2%: cutaneous lesions, 97, 86%, and lesions with mucosal involvement, 16, 14%) than scars (20, 0.25%). Active lesions of both local (100, 88%) and Afghan refugees (13, 12%), and infected age groups were found significantly different. Majority of the lesions were dry crusted (98, 86.7%), single (83, 73%), and frequently infecting facial region (59, 52%). Avoiding bed nets, living in mud houses and animal shelters were highly associated with CL infection. Temergara (30, 26.5%) and Rabath (14, 12.3%) were hyperendemic CL foci. Microscopically, 71 (63%) cases were positive, while the PCR assay revealed Leishmania tropica in 110 (97.3%) cases. Previous record revealed that L. tropica is dominant throughout Pakistan, and dry mountains and plateaus of northwestern and southwestern regions are spatially at high-risk. Measures should be taken to reduce CL infection by eliminating the associated risk factors, promoting PCR-based diagnosis and basic medical facilities.

Cutaneous leishmaniasis: A great imitator

Cutaneous leishmaniasis (CL) is called "the great imitator," because it can mimic almost all types of dermatoses. This similarity may sometimes lead to misdiagnosis, resulting in inappropriate treatment and morbidities. Atypical forms occur due to the interaction between parasitic factors and the host immune response. Secondary infection or mistreatment of CL can also alter the natural course, resulting in bizarre and misdiagnosed cases. Atypical leishmaniasis should be considered in longstanding and painless lesions that may simulate erysipelas, dermatitis, verruca, herpes zoster, paronychia, and sporotrichosis. Less commonly, sarcoidosis, deep mycosis, basal and squamous cell carcinoma, cutaneous lymphoma, or pseudolymphomalike lesions may need to be considered in the differential diagnosis. A high index of suspicion is required to consider a diagnosis of CL, especially in nonendemic or newly endemic regions. Smear, histopathologic examination, culture, and polymerase chain reaction serve as important tools to differentiate CL from its clinical and histologic look-alikes. CL is discussed from various perspectives, with emphasis on CL and its broad differential diagnosis.

Case Report: Atypical Cutaneous Leishmaniasis in a Patient with Mixed Leishmania guyanensis and Leishmania amazonensis Infection

The disseminated form of leishmaniasis is a serious and rare disease, being diagnosed in 2% of the cutaneous cases registered per year in Brazil. The main characteristic is the appearance of multiple pleomorphic lesions on the cutaneous surface. A 68-year-old male from the rural area of Tocantins, Brazil, presented atypical disseminated cutaneous leishmaniasis (ACL). The clinical course and histopathological and immunological findings presented a mixed pattern that hindered diagnosis and therapeutic management. Molecular typing revealed a mixed infection with Leishmania (V.) guyanensis and Leishmania (L.) amazonensis. Molecular identification of the agents responsible for ACL is important for adequate therapeutic planning, minimizing the possibility of sequellae that impact the quality of life of the patient.

Intraspecies susceptibility of Leishmania (Viannia) braziliensis to antileishmanial drugs: Antimony resistance in human isolates from atypical lesions

Leishmania (Viannia) braziliensis is the most common etiological agent of cutaneous and mucocutaneous leishmaniasis (MCL) in Latin America. An interesting aspect of the disease outcome caused by this species is the appearance of non-ulcerated atypical cutaneous leishmaniasis. Atypical (AT) lesions are often associated with therapeutic failure when treated with antimony(Sb)-based drugs. Refractory cases are not necessarily due to intrinsic parasite drug resistance. The status of in vitro drug susceptibility from L. braziliensis field isolates is less assessed than patient treatment outcome. In this work, L. braziliensis isolated from typical CL (6), MCL (1) and AT (3) lesions and vector (1) were tested for their susceptibility to amphotericin B (AmB), miltefosine (MIL), glucantime (GLU) and non-comercial meglumine antimoniate (MA). Overall, intracellular amastigotes of all isolates were sensitive to the tested antileishmanial drugs except AT lesions-derived strains 316, 330 and 340 that presented in vitro resistance against Sb^V-based drugs. Although susceptible to miltefosine - based on phenotypic screening - intramacrophagic quiescent amastigotes could restore infection. L. braziliensis promastigotes isolated from AT lesions also displayed 29% reduced capacity to infect human monocyte-derived macrophages when compared with parasites obtained from patients with typical lesions, MCL or from sand-fly. These data indicate differences in drug susceptibility and infectiveness among L. braziliensis isolated from patients exhibiting different types of lesions and highlight the importance of its characterization for drug response prediction outcome in clinical practice.

Geospatial and Climatic Patterns Associated With the Distribution of Sand Fly (Diptera: Psychodidae) Vectors of Leishmaniasis in Pakistan

We provide a comprehensive and updated review on the effects of elevation and climatic factors on distribution of sand fly (Diptera: Psychodidae) vectors of cutaneous leishmaniasis (CL) and visceral leishmaniasis (VL) across Pakistan. Our study was undertaken in view of the increasing risk of leishmaniasis, particularly resulting from climatic deviations and political instability in the region. Literature (published and unpublished) on suspected vectors of CL (Phlebotomus sergenti Parrot and Phlebotomus papatasi Scopoli) and VL (Phlebotomus major Yakimoff and Schokhor and Phlebotomus hindustanicus Theodor) was collected, sorted, and utilized in geospatial analysis. P. papatasi and P. sergenti co-occurred in majority of the referenced localities and were generally distributed toward the western and southern parts across a wide range of elevation, whereas P. major and P. hindustanicus were limited to high elevation in cool and humid northern areas of Pakistan. Conversely P. papatasi and P. sergenti exploited diverse ecological settings across the country, being particularly abundant in warm/hot and arid regions.

Variability of Cutaneous Leishmaniasis Lesions Is Not Associated with Genetic Diversity of Leishmania tropica in Khyber Pakhtunkhwa Province of Pakistan

Leishmania tropica is the causative agent of cutaneous leishmaniasis in Pakistan. Here, intraspecific diversity of L. tropica from northern Pakistan was investigated using multilocus microsatellite typing. Fourteen polymorphic microsatellite markers were typed in 34 recently collected L. tropica isolates from Pakistan along with 158 archival strains of diverse Afro-Eurasian origins. Previously published profiles for 145 strains of L. tropica originating from different regions of Africa, Central Asia, Iran, and Middle East were included for comparison. Six consistently well-supported genetic groups were resolved: 1) Asia, 2) Morroco A, 3) Namibia and Kenya A, 4) Kenya B/Tunisia and Galilee, 5) Morocco B, and 6) Middle East. Strains from northern Pakistan were assigned to Asian cluster except for three that were placed in a geographically distant genetic group; Morocco A. Lesion variability among these Pakistani strains was not associated with specific L. tropica genetic profile. Pakistani strains showed little genetic differentiation from strains of Iraq, Afghanistan, and Syria (F_ST = 0.00-0.06); displayed evidence of modest genetic flow with India (F_ST = 0.14). Furthermore, genetic structuring within these isolates was not geographically defined. Pak-Afghan cluster was in significant linkage disequilibrium (I_A = 1.43), had low genetic diversity, and displayed comparatively higher heterozygosity (F_IS = -0.62). Patterns of genetic diversity observed suggest dominance of a minimally diverse clonal lineage within northern Pakistan. This is surprising as a wide clinical spectrum was observed in patients, suggesting the importance of host and other factors. Further genotyping studies of L. tropica isolates displaying different clinical phenotypes are required to validate this potentially important observation.

Atypical presentations of cutaneous leishmaniasis: A systematic review

Cutaneous Leishmaniasis (CL) is endemic in 88 countries, showing relevant prevalences. The aim of this study was to perform a systematic review on atypical lesions of CL around the world, addressing clinico-epidemiological, immunological and therapeutic aspects. A search of the literature was conducted via electronic databases Scopus and PubMed for articles published between 2010 and 2015. The search terms browsed were "cutaneous leishmaniasis", "atypical" and "unusual". Based on the eligibility criteria, 34 out of 122 articles were included in the final sample. Atypical lesions may include the following forms: erythematous volcanic ulcer, lupoid, eczematous, erysipeloid, verrucous, dry, zosteriform, paronychial, sporotrichoid, chancriform and annular. In any cases, they seem to be another disease like subcutaneous and deep mycosis, cutaneous lymphoma, pseudolymphoma, basal and squamous cell carcinoma. The lesions have been reported in the face, cheeks, ears, nose, eyelid, limbs, trunk, buttocks, as well as in palmoplantar and genital regions; sometimes occurring in more than one area. The reason for clinical cutaneous leishmaniasis pleomorphism is unclear but immunosuppression seems to play an important role in some cases. There are no established guidelines for the treatment of atypical cutaneous leishmaniasis. However, pentavalent antimonials remain as first line treatment for all forms of leishmaniasis even for HIV-infected patients and atpical forms. Finally, to diagnose an atypical lesion properly, the focus has to be on the medical history and the origin of the patient, comparing them to the natural history of leishmaniasis and always reminding of possible atypical presentations, to then start searching for the best diagnostic method and treatment, reducing the misdiagnosis rate and, subsequently, controlling the disease progression. Thereby, contributing for breaking the transmission chain of the parasite, due to early correct diagnosis which, in turn, contributes to reduce the prevalence.

Periungual tegumentary leishmaniasis: a diagnostic challenge

Periungual and paronychia-like skin lesions can mimic various diseases, setting up a diagnostic challenge that invariably requires correlation with complementary tests. We report a case of an ulcerated tumor of the nailfold diagnosed as leishmaniasis. Although paronychia-like cutaneous leishmaniasis is a rare variant, its epidemiological relevance in Brazil should prompt dermatologists to include it as a plausible diagnosis thus leading to correct work up and treatment.

Cutaneous Leishmaniasis in Khyber Pakhtunkhwa Province of Pakistan: Clinical Diversity and Species-Level Diagnosis

This study primarily aimed to identify the causative species of cutaneous leishmaniasis (CL) in the Khyber Pakhtunkhwa Province of Pakistan and to distinguish any species-specific variation in clinical manifestation of CL. Diagnostic performance of different techniques for identifying CL was assessed. Isolates of Leishmania spp. were detected by in vitro culture, polymerase chain reaction (PCR) on DNA extracted from dried filter papers and microscopic examination of direct lesion smears from patients visiting three major primary care hospitals in Peshawar. A total of 125 CL patients were evaluated. Many acquired the disease from Peshawar and the neighboring tribal area of Khyber Agency. Military personnel acquired CL while deployed in north and south Waziristan. Leishmania tropica was identified as the predominant infecting organism in this study (89.2%) followed by Leishmania major (6.8%) and, unexpectedly, Leishmania infantum (4.1%). These were the first reported cases of CL caused by L. infantum in Pakistan. PCR diagnosis targeting kinetoplast DNA was the most sensitive diagnostic method, identifying 86.5% of all samples found positive by any other method. Other methods were as follows: ribosomal DNA PCR (78.4%), internal transcribed spacer 2 region PCR (70.3%), culture (67.1%), and microscopy (60.5%). Clinical examination reported 14 atypical forms of CL. Atypical lesions were not significantly associated with the infecting Leishmania species, nor with “dry” or “wet” appearance of lesions. Findings from this study provide a platform for species typing of CL patients in Pakistan, utilizing a combination of in vitro culture and molecular diagnostics. Moreover, the clinical diversity described herein can benefit clinicians in devising differential diagnosis of the disease.

Expression analysis of viscerotropic leishmaniasis gene in Leishmania species by real-time RT-PCR

Viscerotropic leishmaniasis (VTL) is a parasitic disease with non-specific manifestations caused by Leishmania tropica. Specific antigens produced by Viscerotropic leishmaniasis gene have been used for diagnosis of VTL. The aim of this study was to compare the expression level of VTL gene among the viscerotropic L. tropica isolates (n: 3) and visceral L. infantum isolates (n: 4). Also, the expression level was compared in L. tropica (n: 21) and L. major (n: 8) isolates, the main causes of cutaneous leishmaniasis in Iran by real time-RT-PCR. Results showed viscerotropic leishmaniasis gene was expressed in all 3 species; L. tropica, L. major and L. infantum. The most expression rate was in L. tropica and L. major as the cutaneous species and the lowest in visceral isolates including L. infantum and viscerotropic L. tropica strains respectively.

CONCLUSION

Results revealed that VTL gene can play an important role in visceralization process of L. tropica although there are other mechanisms to keep parasite visceralized. According to these primary results, increased the expression level of VTL gene probably could contribute to inhibit the invasive behavior of Leishmania parasites. However, more experimental researches are needed to confirm this idea.

Unusual forms of cutaneous leishmaniasis due to Leishmania major

BACKGROUND

Cutaneous leishmaniasis (CL) due to Leishmania major (L. major) is common in the Middle East; however, this skin infection may be under-diagnosed when it presents atypically.

OBJECTIVE

To highlight the occurrence of uncommon presentations of CL that may elude diagnosis.

MATERIALS AND METHODS

A retrospective study was performed among patients who presented at The Sheba Medical Center between 2005 and 2014 with atypical clinical presentations of CL due to L. major.

RESULTS

Twelve patients with unusual clinical presentations of L. major CL were identified. All infections were acquired in L. major - endemic areas of Israel. The average age was 37 years. The average number of lesions was 2. Nine patients presented with a form that mimicked other forms of CL, such as lupoid, giant ulcer, sporotrichoid and recidivans, and three had a variant resembling other infectious skin diseases, such as erysipeloid and verruciform. All patients required systemic therapy.

CONCLUSION

Cutaneous leishmaniasis due to L. major can masquerade as many other infectious and inflammatory diseases. In addition, it can mimic clinical forms of New World CL. We suggest that in endemic countries or in travellers returning from countries where L. major is endemic, polymerase chain reaction (PCR) for Leishmania-specific DNA should be performed routinely in cases of unusual presentations of dermatitis with a single or a few lesions, even if a diagnosis of CL was not considered by the referring clinician.

[Erysipeloid cutaneous leishmaniasis: about a clinical observation]

Les auteurs rapportent les caractéristiques épidémiologiques et cliniques de la forme érysipéloïde de leishmaniose cutanée ainsi que ses difficultés diagnostiques et thérapeutiques. Chez une patiente âgée de 44 ans, sans antécédents, a consulté pour une tuméfaction nasale inflammatoire évoluant depuis 4 mois. L'examen clinique a révélé un placard érythémateux, infiltré centrofaciale. Une antibiothérapie avec des soins locaux quotidiens n'ont pas entraîné une amélioration, voire l'extension de lésions sous anti-inflammatoire non stéroïdiens. Le diagnostic de leishmaniose cutanée a été confirmé par le frottis cutané. Un traitement par l'antimoniate de méglumine par voie intramusculaire a été instauré à la dose de 20 mg/kg par jour avec évolution favorable. La forme érysipéloïde de leishmaniose cutanée constitue une entité rare et inhabituelle entraînant souvent un retard diagnostique. Le diagnostic repose sur l'examen parasitologique direct, la recherche de l'ADN des leishmanies par PCR et sur l'examen histologique. Et il existe plusieurs options thérapeutiques. L’évolution est généralement favorable.

Zosteriform cutaneous leishmaniasis diagnosed with the help of dermoscopy

Cutaneous leishmaniasis is usually easy to recognize; however, several atypical features exist, which may pose a diagnostic challenge. Here we report a 55-year-old female patient, who presented with an itchy and painful eruption localized in a dermatomal distribution along the right upper chest. Although the clinical appearance of the lesions suggested the diagnosis of herpes zoster, dermoscopic evaluation revealed erythema, hyperkeratosis, burst star whitish appearance and hairpin vessels, compatible with the diagnosis of cutaneous leishmaniasis. Indeed, leishmania amastigotes were detected by smear from the lesions. Zosteriform presentation of cutaneous leishmaniasis, as exemplified by our patient, is especially rare. In our case dermoscopy has proven to be an accessible and easy tool to diagnose such atypical presentation of cutaneous leishmaniasis, and dermatologists in endemic areas should be familiar with its typical dermoscopic features.

Unusual presentation of cutaneous leishmaniasis

Two patients with mini-volcano type of skin lesions which showed histopathologic features of cutaneous leishmaniasis (CL) have been described. It was localised and linear in one case while widespread in the other. Both responded to sodium stibogluconate. The importance of recognising new emerging foci of CL is emphasised.

Clinical pleiomorphism in human leishmaniases, with special mention of asymptomatic infection

This review gives an update of current knowledge on the clinical pleiomorphism of Leishmania, with a special emphasis on the case of asymptomatic carriage. The first part describes the numerous unusual expressions of the disease that occur besides the classic (visceral, cutaneous, and mucocutaneous) forms of leishmaniases. The second part deals with progress in the understanding of disease outcome in humans, and the possible future approaches to improve our knowledge in the field. The third part highlights the role of the too often neglected asymptomatic carrier compartment. This group could be key to understanding infraspecific differences in virulence and pathogenicity of the parasite, as well as identifying the genetic determinants involved in the expression of the disease.

Clinical manifestations and distribution of cutaneous leishmaniasis in pakistan

Cutaneous leishmaniasis (CL) is a rising epidemic in Pakistan. It is a major public health problem in the country especially alongside regions bordering the neighboring Afghanistan and cities that have had the maximum influx of refugees. The purpose of our paper is to highlight the diverse clinical manifestations of the disease seen along with the geographic areas affected, where the hosts are particularly susceptible. This would also be helpful in presenting the broad spectrum of the disease for training of health care workers and help in surveillance of CL in the region. The increased clinical diversity and the spectrum of phenotypic manifestations noted underscore the fact that the diagnosis of CL should be not only considered when dealing with common skin lesions, but also highly suspected by dermatologists and even primary care physicians even when encountering uncommon pathologies. Hence, we would strongly advocate that since most of these patients present to local health care centers and hospitals, primary care practitioners and even lady health workers (LHWs) should be trained in identification of at least the common presentations of CL.

Cutaneous leishmaniasis caused by Leishmania (L.) major infection in Sindh province, Pakistan

Leishmaniasis is endemic in Pakistan and is wide-spread throughout the country. Polymerase chain reaction (PCR) was performed to identify the Leishmania species present in cutaneous leishmaniasis (CL) patients from new endemic areas of the central part of Sindh province, Pakistan. The PCR primers used were designed for the identification and differentiation of Leishmania (Leishmania) major and Leishmania (Leishmania) tropica species, and PCR bands at 620 and 830 bp of the parasite-specific kinetoplast DNA sequences was identified for L. (L.) major and L. (L.) tropica, respectively. Among a total of 144 DNA samples purified from the skin biopsies of clinically suspected CL patients, 108 (75%) were positive for PCR amplification. Out of the 108 cases, 105 (97.2%) were determined to be positive for L. (L.) major infection, and 3 (2.8%) were positive for L. (L.) tropica infection. It was concluded that CL caused by L. (L.) major is the main source of infection in the central part of Sindh province in Pakistan. This rapid screening technique could be used for the diagnosis of a large number of samples from skin lesions, which commonly contain other bacterial and fungal infections.

[Anatomo-clinical features of an erysipeloid form of cutaneous leismaniasis in Tunisia]

The erysipeloid form of cutaneous leishmaniasis is considered as an unusual and rare clinical presentation in Tunisia. Our prospective study on 4 observations, aimed at examining the clinical, histological and progressive features of the "erysipeloid" form of cutaneous leishmaniasis. Our patients were 3 females and one male more than 62 years old. Their cutaneous leishmaniasis was clinically characterised by an infiltrated and extensive plaque which was localised on the face covering the nose and cheeks looking like erysipelas. The treatment was intramuscular meglumine antimoniate (Glucantime) in three cases and metronidazole in one case. A regression without scar was noticed in all the cases. On the histological examination, we observed an intense epidermic and constant hyperplasia with presence of amastigotes in 3 cases. Our study shows the lesional polymorphism of the old word cutaneous leishmaniasis in our region. The "erysipeloid" form of cutaneous leishmaniasis is a rare clinical presentation which generally affects women. If the clinical aspect is very meaningful, the histological aspect is meaningful but not specific.

[Cutaneous leishmaniasis in rheumatoid arthritis]

INTRODUCTION

Cutaneous leishmaniasis is a protozoal infection. Its prevalence is increasing, especially in immunocompromised subjects.

CASE REPORTS

We report four patients with rheumatoid arthritis, treated with methotrexate and prednisone who developed cutaneous leishmaniasis. Clinical outcome was favorable after institution of antimony therapy in three cases despite the continuation of methotrexate and prednisone. One patient failed to respond to therapy.

DISCUSSION

The frequency of cutaneous leishmaniasis is increasing especially in immunocompromised subjects. In our patients, rheumatoid arthritis, corticosteroid therapy and methotrexate were predisposing factors of cutaneous leishmaniasis.

Genetic susceptibility to infectious disease: lessons from mouse models of leishmaniasis

Susceptibility to infectious disease is influenced by multiple host genes, most of which are low penetrance QTLs that are difficult to map in humans. Leishmaniasis is a well-studied infectious disease with a variety of symptoms and well-defined immunological features. Mouse models of this disease have revealed more than 20 QTLs as being susceptibility genes, studies of which have made important contributions to our understanding of the host response to infection. The functional effects of individual QTLs differ widely, indicating a networked regulation of these effects. Several of these QTLs probably also influence susceptibility to other infections, indicating that their characterization will contribute to our understanding of susceptibility to infectious disease in general.

Bacterial infections: uncommon presentations

The essence of dermatology is morphology. The most important instrument in the practice of dermatology has always been, and still is, the naked eye; however, "We see only what we are ready to see, what we have been taught to see" (Jean Martin Charcot). Although most practitioners will easily correctly diagnose common bacterial skin diseases (such as cellulitis, erysipelas, impetigo, etc), only a trained and updated dermatologist will recognize the unusual forms and rare variants of these diseases. Bacterial skin diseases are sometimes acute and life-threatening. The mortality rates from necrotizing fasciitis range from 20% to 40%, to name just one example. It is not unreasonable to expect that dermatologists, whether in clinical practice or in referral centers, will be the first physicians to be confronted with unusual variants of bacterial skin diseases that have been unrecognized by non-dermatologists. Some of these cases might even be life-threatening, and only prompt and early recognition, diagnosis, and treatment can make the difference between losing and saving a patient's life. In short, we dermatologists should hone our clinical diagnostic skills and expand our knowledge of the rare forms and unusual and atypical variants of skin diseases: the textbook variants will probably be recognized and treated by general practitioners.

Rare variants of Cutaneous Leishmaniasis: Whitlow, paronychia, and sporotrichoid

Cutaneous Leishmaniasis is endemic in certain areas of Pakistan, with the wet form of the disease being the most prevalent. It has a number of morphological variants, which are dependent on the immune status of the host, the subspecies of the Leishmania, and also, to some extent, on the site of involvement. We describe here a case of Leishmaniasis showing two very rare variants, whitlow and paronychial lesions, occurring concurrently with sporotrichoid spread. The patient responded to intramuscular sodium stibogluconate with resolution of the skin lesions.

Detection of new endemic areas of cutaneous leishmaniasis in Pakistan: a 6-year study

BACKGROUND

Cutaneous leishmaniasis (CL) is endemic in Pakistan and is widely spreading. Recently, an outbreak of the disease was observed in the region. We report some new endemic areas of CL in the country.

METHODS

A total of 1210 cases of CL who visited our department from 1996 to 2001 are reported. Among them, 760 were residents of the Jacobabad, Larkana, and Dadu districts of Sindh province and had never previously traveled to endemic areas. These districts have never been reported/recognized as endemic for CL. Others were residents of endemic areas of Balochistan province. Diagnosis was made on clinical presentation; a giemsa-stained smear test and histopathological results. All the cases were treated with the meglumine antimoniate 600 mg/day (adults) and 15 mg/kg/day (children) intramuscularly for 20 consecutive days.

RESULTS

All the patients were aged between 2.5 months and 65 years. Three hundred and ninety-two patients were females and 368 were males. Duration of the disease ranged from 2 to 18 months. Most of the patients had a single lesion on the face and/or extremities. Clinically, the disease was classified as: dry papular type, 407 cases; dry ulcerative type, 335 cases; and wet ulcerative type, 18 cases. No cases of muco-cutaneous or visceral leishmaniasis were found during this period. Smear testing was positive in 845 cases, while 365 cases were histopathologically positive. An ultrastructural study was performed using specimens of a few of the cases. Leishmania parasites were detected in the dermal tissues as well as in the macrophages.

CONCLUSIONS

We propose that the Jacobabad, Larkana and Dadu districts could be considered endemic for CL. Wet- and dry-type lesions indicate the presence of both Leishmania tropica and L. major in this tropical region.