Generalized cutaneous leishmaniasis in acquired immunodeficiency syndrome

Cutaneous leishmaniasis: A neglected disfiguring disease for women

Leishmaniasis is one of eight neglected tropical diseases currently endemic in 102 countries/areas around the world. In recent years, cutaneous leishmaniasis (CL) has been increasingly observed among migrants, travelers, ecotourists, and military personnel. Because of its great capacity to mimic other dermatoses, CL is one of the great imitators and can mislead practitioners, which can result in untreated lesions that cause scars. CL is a disfiguring disease, especially for women, and often leaves scars on visible body sites, causing psychological, social, and economic problems. CS is a challenge, especially in nonendemic regions, such as Australia, because experience with diagnosis and management of the disease is limited.

The Binomial Parasite-Host Immunity in the Healing Process and in Reactivation of Human Tegumentary Leishmaniasis

Leishmaniasis is a vector-borne infectious disease caused by different species of protozoa from the Leishmania genus. Classically, the disease can be classified into two main clinical forms: Visceral (VL) and Tegumentary (TL) leishmaniasis. TL is a skin/mucosal granulomatous disease that manifests mainly as cutaneous localized or disseminated ulcers, papules diffusely distributed, mucosal lesions or atypical lesions. Once the etiology of the infection is confirmed, treatment can take place, and different drugs can be administered. It has already been shown that, even when the scar is clinically evident, inflammation is still present in the native tissue, and the decrease of the inflammatory process occurs slowly during the 1st years after clinical healing. The maintenance of residual parasites in the scar tissue is also well documented. Therefore, it is no longer a surprise that, under some circumstances, therapeutic failure and/or lesion reactivation occurs. All over the years, an impressive amount of data on relapses, treatment resistance and lesion reactivation after healing has been collected, and several factors have been pointed out as having a role in the process. Different factors such as Leishmania species, parasite variability, Leishmania RNA virus 1, parasite load, parasite persistence, age, nutritional status, gender, co-morbidities, co-infection, pregnancy, immunosuppression, lesion duration, number and localization of lesions, drug metabolism, irregular treatment and individual host cellular immune response were described and discussed in the present review. Unfortunately, despite this amount of information, a conclusive understanding remains under construction. In addition, multifactorial influence cannot be discarded. In this context, knowing why leishmaniasis has been difficult to treat and control can help the development of new approaches, such as drugs and immunotherapy in order to improve healing maintenance. In this sense, we would like to highlight some of the findings that may influence the course of Leishmania infection and the therapeutic response, with an emphasis on TL.

Cutaneous leishmaniasis in a severely immunocompromised HIV patient in Kumbo, Northwest region of Cameroon: case report

Background

Leishmaniasis is a rising opportunistic infection in individuals with human immunodeficiency virus (HIV). Cases of leishmania and HIV co-infection have been documented in several countries in the world with most reporting on the association between visceral leishmaniasis (VL) and HIV. We herein report the case of cutaneous leishmaniasis (CL) occurring in an HIV seropositive patient.

Case presentation

A 28 year old Cameroonian female diagnosed with HIV for 6 months earlier, presented to our facility with a 3 months history of non-painful rash. Clinical examination revealed non prurigeneous papulo-nodular lesions on the face and thighs which later became crusty ulcerative lesions. Giemsa staining with examination under oil objective immersion identified amastigotes and a diagnosis of CL was made which was managed with amphotericine B (1 mg/kg of body weight) for 14 days with mild improvement of lesions. Patient developed hypokalemia due to the amphotericine B during admission which was corrected and died 1 month after discharge.

Conclusions

Current evidence suggest higher incidence of VL in HIV, however we report the occurrence of CL in HIV. A high index of suspicion for CL is warranted among clinicians in Africa when faced with HIV patients with inconsistent cutaneous rash.

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.

PKDL and other dermal lesions in HIV co-infected patients with Leishmaniasis: review of clinical presentation in relation to immune responses

Background

Co-infection of leishmaniasis and HIV is increasingly reported. The clinical presentation of leishmaniasis is determined by the host immune response to the parasite; as a consequence, this presentation will be influenced by HIV-induced immunosuppression. As leishmaniasis commonly affects the skin, increasing immunosuppression changes the clinical presentation, such as in post-kala-azar dermal leishmaniasis (PKDL) and cutaneous leishmaniasis (CL); dermal lesions are also commonly reported in visceral leishmaniasis (VL) and HIV co-infection.

Methods

We reviewed the literature with regard to dermal manifestations in leishmaniasis and HIV co-infection, in three clinical syndromes, according to the primary presentation: PKDL, VL, or CL.

Results

A wide variety of descriptions of dermal leishmaniasis in HIV co-infection has been reported. Lesions are commonly described as florid, symmetrical, non-ulcerating, nodular lesions with atypical distribution and numerous parasites. Pre-existing, unrelated dermal lesions may become parasitized. Parasites lose their tropism and no longer exclusively cause VL or CL. PKDL in HIV co-infected patients is more common and more severe and is not restricted to Leishmania donovani. In VL, dermal lesions occur in up to 18% of patients and may present as (severe) localized cutaneous leishmaniasis, disseminated cutaneous leishmaniasis (DL) or diffuse cutaneous leishmaniasis (DCL); there may be an overlap with para-kala-azar dermal leishmaniasis. In CL, dissemination in the skin may occur resembling DL or DCL; subsequent spread to the viscera may follow. Mucosal lesions are commonly found in VL or CL and HIV co-infection. Classical mucocutaneous leishmaniasis is more severe. Immune reconstitution disease (IRD) is uncommon in HIV co-infected patients with leishmaniasis on antiretroviral treatment (ART).

Conclusion

With increasing immunosuppression, the clinical syndromes of CL, VL, and PKDL become more severe and may overlap. These syndromes may be best described as VL with disseminated cutaneous lesions (before, during, or after VL) and disseminated cutaneous leishmaniasis with or without visceralization.

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.

Th1/Th2 cytokine profile in patients coinfected with HIV and Leishmania in Brazil

To evaluate the effects of HIV on immune responses in cutaneous leishmaniasis (CL), we quantified cytokine levels from plasma and stimulated peripheral blood mononuclear cells (PBMCs) from individuals infected with HIV and/or CL. Gamma interferon (IFN-γ) and interleukin 13 (IL-13) levels and the ratio of IFN-γ to IL-10 produced in response to stimulation with soluble Leishmania antigens were significantly lower in HIV-Leishmania-coinfected patients than in CL-monoinfected patients.

L. (L.) chagasi in AIDS and visceral leishmaniasis (kala-azar) co-infection

Concomitant skin lesions in visceral leishmaniasis (VL) or kala-azar are rare, being more common the description of post-kala-azar dermal leishmaniasis occurring post treatment of kala-azar. Skin lesions caused by Leishmania donovani are frequently seen in the aids-VL co-infection. In Brazil cutaneous or mucosal forms of tegumentary leishmaniasis concomitant with aids are more commonly registered. Here we present a case of aids-VL co-infection, with unusual cutaneous and digestive compromising attributed to L. (L.) chagasi, with special attention to ecthymatous aspect of the lesion, allied to the absence of parasite on the histological skin biopsy.

The relationship between leishmaniasis and AIDS: the second 10 years

To date, most Leishmania and human immunodeficiency virus (HIV) coinfection cases reported to WHO come from Southern Europe. Up to the year 2001, nearly 2,000 cases of coinfection were identified, of which 90% were from Spain, Italy, France, and Portugal. However, these figures are misleading because they do not account for the large proportion of cases in many African and Asian countries that are missed due to a lack of diagnostic facilities and poor reporting systems. Most cases of coinfection in the Americas are reported in Brazil, where the incidence of leishmaniasis has spread in recent years due to overlap with major areas of HIV transmission. In some areas of Africa, the number of coinfection cases has increased dramatically due to social phenomena such as mass migration and wars. In northwest Ethiopia, up to 30% of all visceral leishmaniasis patients are also infected with HIV. In Asia, coinfections are increasingly being reported in India, which also has the highest global burden of leishmaniasis and a high rate of resistance to antimonial drugs. Based on the previous experience of 20 years of coinfection in Europe, this review focuses on the management of Leishmania-HIV-coinfected patients in low-income countries where leishmaniasis is endemic.

Biologia molecular aplicada às dermatoses tropicais

São apresentados conceitos básicos sobre célula, código genético e síntese protéica, e sobre algumas técnicas de biologia molecular, tais como PCR, PCR-RFLP, seqüenciamento de DNA, RT-PCR e immunoblotting. São fornecidos protocolos de extração de nucleotídeos e de proteínas, como salting out no sangue periférico e métodos do fenol-clorofórmio e do trizol em tecidos. Seguem-se exemplos comentados da aplicação de técnicas de biologia molecular para o diagnóstico etiológico e pesquisa em dermatoses tropicais, com ênfase na leishmaniose tegumentar americana e hanseníase.

Oral leishmaniasis: a clinicopathological study of 11 cases

Leishmaniasis is a parasitic disease with diverse clinical manifestations, and considered a public health problem in endemic countries such as Brazil. Mucosal lesions usually involve the upper respiratory tract, with a predilection for nose and larynx. Oral involvement is unusual and in most cases it becomes evident after several years of resolution of the original cutaneous lesions. Oral lesions classically appear as mucosal ulcerations, mainly in the hard or soft palate. This report describes the clinicopathological data of 11 cases of mucocutaneous leishmaniasis with oral manifestations. Two cases of Leishmania (Viannia) braziliensis and one case of Leishmania (Leishmania) amazonensis were confirmed by polymerase chain reaction-restriction fragment length polymorphism or DNA sequencing in mucosal samples.

Cutaneous Infections Associated with HIV/AIDS

With diminished and dysregulated cell-mediated immunity, HIV-infected individuals are susceptible to a myriad of skin infections. These infections include the conditions encountered in immunocompetent patients, as well as infections seen almost exclusively in the setting of HIV infection. The HIV/AIDS pandemic has made some previously rare infections more prominent. Although antiretroviral therapy has been helpful in relieving the burden of cutaneous infections in HIV-infected patients, it does not prevent all opportunistic infections in the skin and also has created new dilemmas.

Leishmania/HIV co-infection in Brazil: an appraisal

Given the epidemiology of human leishmaniasis and AIDS in Brazil, numerous cases of Leishmania/HIV co-infection might be expected. Relatively few Brazilian cases have been reported, however, even from regions where the overall incidences of HIV and Leishmania infection are both relatively high. Many cases of co-infection probably go undetected because of a lack of awareness among clinicians or limited access to appropriate diagnostic methods. In contrast to the situation in Europe, intravenous-drug users do not predominate among those exposed to HIV infection in Brazil. The success of the Brazilian programme for the free and universal distribution of antiretroviral drugs has decreased the prevalences of the commoner opportunistic infections among HIV-positives and increased the longevity of AIDS cases. Recent changes in the epidemiological patterns of HIV and Leishmania infections are likely to lead to a greater degree of overlap and a greater risk of co-infection and they justify increased alertness. This review of the co-infection in Brazil addresses three main topics: the current situation, in terms of the epidemiology of AIDS and Leishmania infection; the related epidemiological trends and their likely impact on the co-infection; and the co-infection cases reported in Brazil by June 2003.

Leishmania and HIV co-infection: dermatological manifestations

Leishmania species can cause a wide spectrum of cutaneous disease in HIV-positive patients: asymptomatic, localized cutaneous, mucosal, muco-cutaneous, diffuse cutaneous or post-kala-azar leishmaniasis. In such cases, which are usually severely immunocompromised, the leishmanial parasites reach the skin of the human host by dissemination after either a new infection (resulting from the bite of infected sandfly or, probably, the sharing of contaminated syringes by intravenous-drug users) or the re-activation of a latent infection. Recent experience and past observations on the dermatology of leishmaniasis in those with Leishmania/HIV co-infection are reviewed here.

Old world cutaneous leishmaniasis in Los Angeles: a case report, overview of the current literature, and guide for the treating dermatopathologist

We describe a case of cutaneous leishmaniasis in a Spanish patient visiting Los Angeles. Leishmania species cause both cutaneous and visceral disease; the majority of infections with Leishmania are of the cutaneous form. Although leishmaniasis is a relatively rare occurrence in the United States, travel by United States' citizens to endemic regions and increased United States military operations in the Middle East raise the chances of encountering cutaneous leishmaniasis. The following case report and overview of the current literature outlines the major morphologic findings and current diagnostic modalities available to diagnose cutaneous leishmaniasis.

Leishmaniasis: recognition and management with a focus on the immunocompromised patient

Leishmaniasis is a protozoan disease whose clinical manifestations depend both on the infecting species of Leishmania and the immune response of the host. Transmission of the disease occurs by the bite of a sandfly infected with Leishmania parasites. Infection may be restricted to the skin in cutaneous leishmaniasis (CL), to the mucous membranes in mucosal leishmaniasis or spread internally in visceral leishmaniasis (VL). In the last 2 decades, leishmaniasis, especially VL, has been recognized as an opportunistic disease in immunocompromised patients, particularly those infected with HIV. Leishmaniasis is characterized by a spectrum of disease phenotypes that correspond to the strength of the host's cell-mediated immune response. Both susceptible and resistant phenotypes exist within human populations. Clinical cutaneous disease ranges from a few spontaneously-healing lesions, to diffuse external or internal disease, to severe mucous membrane involvement. Spontaneously-healing lesions are associated with positive antigen-specific T cell responsiveness, diffuse cutaneous and visceral disease with T cell non-responsiveness, and mucocutaneous disease with T cell hyperresponsiveness. Current research is focused on determining the extent to which this spectrum of host response is genetically determined. In endemic areas, diagnosis is often made on clinical grounds alone including: small number of lesions; on exposed areas; present for a number of months; resistant to all types of attempted treatments; and usually no pain or itching. Multiple diagnostic techniques are available. When evaluating treatment, the natural history of leishmaniasis must be considered. Lesions of CL heal spontaneously over 1 month to 3 years, while lesions of mucocutaneous and VL rarely, if ever, heal without treatment. Consequently, all the latter patients require treatment. Therapy is not always essential in localized CL, although the majority of such patients are treated. Patients with lesions on the face or other cosmetically important areas are treated to reduce the size of the resultant scar. In addition, the species of parasite should be identified so that infection with Leishmania braziliensis and Leishmania panamensis can be treated to reduce the risk of development of mucocutaneous disease. Treating patients with Leishmania and HIV co-infection requires close monitoring for effectiveness of treatment, especially because of the high relapse rates. Proven treatments include: antimonials, pentamidine, amphotericin B, interferon with antimony. Treatments where current clinical experience is too limited include: allopurinol, ketoconazole, itraconazole, immunotherapy, rifampin, dapsone, localized heat, paromomycin ointment and cryotherapy. Investigational treatments include: WR6026, liposomal amphotericin and miltefosine. In addition, vaccines for leishmaniasis are being investigated in clinical trials.

Leishmaniasis as an emerging infection

Leishmaniasis is a protozoan disease whose diverse clinical manifestations are dependent both on the infecting species of Leishmania and the immune response of the host. Transmission of the disease occurs by the bite of a sand fly infected with Leishmania parasites. Infection may be restricted to the skin in cutaneous leishmaniasis, limited to the mucous membranes in mucosal leishmaniasis, or spread internally in visceral leishmaniasis or kala azar. The overall prevalence of leishmaniasis is 12 million cases worldwide, and the global yearly incidence of all clinical forms approaches 2 million new cases (World Health Organization WHO/ LEISH/200.42, Leishmania/HIV Co-Infection in Southwestern Europe 1990-98: Retrospective Analysis of 965 Cases, 2000). In the last two decades, leishmaniasis, especially visceral leishmaniasis, has been recognized as an opportunistic disease in the immunocompromised, particularly in patients infected with human immunodeficiency virus.

Leishmaniasis phytotherapy. Nature's leadership against an ancient disease

The use of phytotherapy to treat human diseases has its roots in pre-historical times. Despite the modern advances achieved in the field of synthetic chemistry, the most efficient drugs available have their genesis directly or indirectly related with the vegetal kingdom. Indigenous communities have long used plant extracts to treat illnesses. Many of these extracts have shown effective action, with new bioactive compounds being extracted and screened every year. These extracts have also proven to be good sources of therapeutic agents to the treatment of Leishmaniasis. This work highlights some of these agents, while trying to emphasize the importance of plants as a source of new and powerful drugs against this widespread disease.