Two Cases of Oral Pharyngeal Leishmaniasis Treated with Pentamidine

2. Mucosal leishmaniasis

Sudanese mucosal leishmaniasis is a chronic infection of the upper respiratory tract and/or oral mucosa caused mainly by Leishmania donovani. The disease occurs in areas of the country endemic for visceral leishmaniasis, particularly among Masalit and other closely related tribes in western Sudan. The condition may develop during or after an attack of visceral leishmaniasis, but in most cases it is a primary mucosal disease. Unlike South American mucocutaneous leishmaniasis, mucosal leishmaniasis in Sudan is not preceded or accompanied by a cutaneous lesion. Pathologically, the lesions show a mixture of macrophages, plasma cells and lymphocytes. An epithelioid granuloma may also be found. Parasites are scanty. Diagnosis is established by demonstration of parasites in smears or biopsies, by culture or animal inoculation, or with the aid of the polymerase chain reaction. Most patients give positive results in the direct agglutination test and leishmanin skin test. Patients respond well to treatment with pentavalent antimony compounds.

Sudanese mucosal leishmaniasis: epidemiology, clinical features, diagnosis, immune responses and treatment

The epidemiology, clinical features, pathology, immune responses, diagnosis and treatment of 14 patients with mucosal leishmaniasis in the Sudan are described. The condition occurred mainly in adult males, particularly in certain closely related tribes from the western Sudan. It affected the mucosa of the upper respiratory tract and/or the oral mucosa and sometimes followed treated kala azar. The parasites were sometimes confined to the mucosa, sometimes spread to the lymph nodes, and rarely infected the bone marrow and spleen. One of the 2 patients with both visceral and mucosal leishmaniasis differed from classical kala azar cases; his infection was longer lasting, he was leishmanin positive, and his peripheral mononuclear cells proliferated in response to leishmanial antigens. Mucosal leishmaniasis following treated kala azar is a similar phenomenon to post-kala azar dermal leishmaniasis and post-kala azar uveitis. Post-kala azar mucosal leishmaniasis can therefore be added to the other post-kala azar leishmanial infections. Using the polymerase chain reaction, Southern blot analysis with specific probes, and isoenzyme characterization, the causative parasite was identified as Leishmania donovani in 4 patients and as L. major in one. Unlike American mucocutaneous leishmaniasis, mucosal leishmaniasis in the Sudan was not preceded or accompanied by cutaneous lesions and the response to pentavalent antimony or ketoconazole was good.

Sudan mucosal leishmaniasis

New cases of mucosal leishmaniasis and the first case of espundia-like muco-cutaneous leishmaniasis are reported from the Sudan. Cases previously reported are reviewed and the geographical distribution, clinical features, pathology, immunology and treatment of the disease are described. The majority of cases came from the known kala azar endemic regions of the central Sudan. The disease was seen in adult males, it commonly affected the mouth and nose causing in some cases permanent damage to teeth and nasal septi. In the lesions, the cellular infiltrate was composed mainly of histiocytes, lymphocytes and plasma cells. The number of parasites present was inversely related to the number of lymphocytes but was not related to the number of plasma cells. The level of the increased serum immunoglobulins was not constantly correlated with the number of any particular cell in the infiltrate. Treatment with sodium stibogluconate (Pentostam) was effective in the majority of cases.