Mucocutaneous leishmaniasis: a review of clinical aspects

Dry type leishmanial lymphadenitis presented as two large parotid and cervical masses

BACKGROUND

Cutaneous leishmanisis (CL) is a common disease in Iran, particularly in Kerman and Bam and Kerman province. Lymphadenitis resulting from leishmania tropica (dry type) with, or without, cutaneous lesion is rare. Localized leishmanial lymphadenitis (LLA) is a specific clinico-pathologic presentation of inflammatory changes caused by leishmanial parasites or antigen within an isolated lymph node without any systemic manifestation.

CASE REPORT

A 55-year-old Iranian woman presented with two slow growing large nodules (masses) on the left preauricular and the left cervical areas. The nodules were large, painless, mobile, multilobulated, and associated with a small skin papule on the left-side of the cheek distal to the masses.

RESULTS

Histopathologic examination of both the skin lesion and the lymph nodes suggested the leishmanial etiology of skin papule and lymphadenitis. The Leishman-bodies (amastigotes) were demonstrated in two lymph nodes and a skin lesion. The clinical picture plus pathological finding and the response to meglumine-antimoniate confirmed LLA.

CONCLUSION

Lymph node involvement is another rare manifestation of dissemination of infection with dermotropic leishmania. This presentation of CL should not be treated with the ordinary local treatments such as curettage, cryotherapy or surgical excision.

American cutaneous leishmaniasis unresponsive to antimonial drugs: successful treatment using combination of N-methilglucamine antimoniate plus pentoxifylline

BACKGROUND

American cutaneous leishmaniasis is characterized by single or multiple ulcerations. Cytokines, among other factors, have been shown to influence lesion development and tumoral necrosis factor-alpha is a major cytokine implicated in pathogenesis of ulcers.

OBSERVATIONS

We tested oral pentoxifylline, a known tumoral necrosis factor-alpha inhibitor, at doses of 400 mg (2-3x/day), associated to N-methylglucamine antimoniate (15 mg/kg/day) in two patients with American cutaneous leishmaniasis unresponsive to antimonial drugs. We observed a satisfactory response with quick cure of skin lesions of these patients.

CONCLUSIONS

Our results suggest that oral pentoxifylline in association to N-methylglucamine antimoniate should be consider in refractory cutaneous leishmaniasis patients.

Cutaneous leishmaniasis in Tupí-Mondé Amerindians from the Brazilian Amazonia

This paper reports the results of a cross-sectional survey aimed at characterizing the epidemiology of American cutaneous leihsmaniasis (ACL) in 3 Tupí-Mondé-speaking Amerindian groups from the Brazilian Amazon region. Data include results of Montenegro skin tests (n = 550), serology (n = 233), and physical examinations (n = 676). Rates of skin test positivity were higher for males and differed between the groups (Gavião 43.0%, Suruí 52.8%, Zoró 68.1%), with a trend toward increase with age. Strong associations were also detected for the presence of suggestive ACL scars, on the one hand, and age, sex, and tribal affiliation, on the other. Although 14.7% of the subjects showed typical scars of past ACL disease, only 3 cases of active primary leishmanial ulcers were observed. The results did not indicate any clear association between seropositivity and positivity to the Montenegro intradermal test or presence of scars. The authors discuss the epidemiology of ACL in the Tupí-Mondé in the light of their ecology and recent history.

Fifteen years of cutaneous and mucocutaneous leishmaniasis in Bolivia: a retrospective study

This paper present the results of a retrospective study of cases of cutaneous and mucocutaneous leishmaniasis in Bolivia between 1975 and 1991. The total number of cases reported was 4058, 739 of which were mucous. Three different areas of endemic leishmaniasis are defined in Bolivia.

[Cutaneous leishmaniasis in the Western region of the State of Santa Catarina, Brazil]

A survey was performed among 22 patients with ulcers suspected of leishmanial origin in the municipalities of Quilombo and Coronel Freitas, west of Santa Catarina State. From 5 patients only smears from the ulcers were examined, 5 others were submitted to Montenegro's intradermal test and in 8 both methods were used. Cases were regarded as confirmed when: 1. parasites were found in the ulcer smears; 2. the lesions were clinically characteristic and the skin test was positive and 3. the clinically characteristic lesions healed after specific treatment. Fourteen patients were regarded as confirmed cases, 11 being autochthonous, showing that transmission of cutaneous leishmaniasis occurs in the State. Of the autochthonous cases 5 showed parasites in the skin smears. Most patients were males and all were older than 15 years of age.

Dissemination in cutaneous leishmaniasis. 3. Lymph node involvement

In a study of zoonotic cutaneous leishmaniasis (CL) due to leishmania major in an endemic focus in Saudi Arabia, lymph node enlargement was observed in 66 of 643 patients (10.26%). The epitrochlear lymph nodes were most commonly involved (68%), but cervical (11%), axillary (15%), and inguinal (18%) lymph nodes were also involved. In eight patients (12%), two lymph node areas were involved. The affected lymph nodes were typically solitary, firm, mobile, nontender, only moderately enlarged, and appeared to persist beyond the clinical healing of the associated skin lesions. The results of pathologic and immunopathologic studies carried out on eight lymph nodes obtained from this group of patients supported the leishmanial etiology. Although amastigotes were only demonstrated in two lymph nodes, the leishmanial antigen was found in all eight specimens. The lymph node involvement is another manifestation of dissemination in infection with a dermotropic leishmania. It appears that in some cases, instead of the parasite, it may be the leishmanial antigen that disseminates and produces lymphadenitis.

Cutaneous leishmaniasis in Bolivia. A study of 185 human cases from Alto Beni (La Paz Department). Isolation and isoenzyme characterization of 26 strains of Leishmania braziliensis braziliensis [corrected]

A clinical, serological, parasitological and therapeutic study of cutaneous leishmaniasis was carried out in a low sub-andean area (250-800 metres) of the La Paz Department, Bolivia. A team of seismic prospectors (350 workers) was surveyed for 12 months. Of 200 suspected cases of cutaneous leishmaniasis, 185 were serologically or parasitologically confirmed (incidence 52.8%). Those exposed to the greatest risk of infection were working in a virgin forest environment. Leishmanial organisms were isolated from 26 of the workers, either by in vitro cultivation or inoculation into hamsters. Isoenzyme characterization of the organisms by cellulose acetate electrophoresis showed them to be Leishmania braziliensis braziliensis [corrected]. The results of treatment of 168 patients with a pentavalent antimonial drug are also reported.

Mucosal leishmaniasis ("espundia" Escomel, 1911)

One of the more serious clinical forms of leishmaniasis occurs in espundia when the mucosae of the upper respiratory passages are inflamed. This complication is a metastasis from a skin lesion caused by Leishmania braziliensis braziliensis (Lbb) although cases have been described associated with other leishmanial species. Epidemiological data suggest that a detectable mucosal metastasis occurs in fewer than 5% of patients infected with Lbb in our study area. The determinants of this complication are still largely obscure. The granuloma usually commences on the nasal septum. In about two-thirds of our patients the lesion remained restricted to the nose. In the rest the pharynx, palate, larynx and lips were involved, in this order. It is often difficult to isolate the parasite and for routine diagnosis the leishmanin skin reaction and serological tests are helpful. Although a serious condition, with possible mutilation and even death as subsequent complications, treatment is still mainly with pentavalent antimonials, introduced 40 years ago. These are most unsatisfactory for field use, being given parenterally and relatively toxic. In mucosal leishmaniasis, if sufficient antimony can be administered in a regular daily dose, the relapse rate is small (3 of 42 patients followed for a mean of 5 years). Also, antimony treatment of the initial skin ulcer due to Lbb followed for a mean of 4 years of 83 patients resulted in subsequent mucosal metastasis in only 2. Since espundia is relatively rare, specific treatment targeted to this specific problem is the efficient short term solution. At present there is no satisfactory alternative drug to those in current use.

Human mucocutaneous leishmaniasis in Três Braços, Bahia - Brazil: an area of Leishmania braziliensis braziliensis transmission. II. Cutaneous disease. Presentation and evolution

The clinical records of 182 patients with cutaneous leishmaniasis probably due to Leishmania braziliensis braziliensis are analysed. 68% had a single lesion which was usually an ulceron the lower anterior tibial third. Many had short histories of one to two months and all age groups were represented 13% had closed lesions of a verrucose or plaque like nature. Evolution of these skin lesions after treatment was related to the regularity of antimony therapy. Although healing usually occurred in three months, the time to scarring after commencing treatment was variable and related to the size ofthe lesion (p < 0.01). Usually if sufficient antimony treatment was given the lesion closed. Seven of the ten patients with initially negative leishmanin skin tests converted to positive after treatment. A significant decline of indirect fluorescent antibody titres occurred in patients followed, during and after therapy.

Leishmanial infections: a consideration in travellers returning from abroad

Seven cases of leishmaniasis, including a fatal case of visceral leishmaniasis and 6 cases of dermal leishmaniasis, were seen in Boston over a four-year period. Diagnosis was made by isolation of organisms in culture or by identification of organisms in stained preparations of tissue. Proper management of patients with leishmanial infections requires an appreciation of the geographical strain differences of each species.

Leishmaniasis in Brazil: XV. Biochemical distinction of Leishmania mexicana amazonensis, L. braziliensis braziliensis and L. braziliensis guyanensis--aetiological agents of cutaneous leishmaniasis in the Amazon Basin of Brazil

Enzymic profiles of the three known agents of human cutaneous leishmaniasis in the lower Amazon region are compared. Of 14 enzymes, 10 (ASAT, ALAT, GPI, G5PD, MDH, ACON, PEP, HK, MPI and ACP) differentiate Leishmania mexicana amazonensis from L. braziliensis braziliensis or L. braziliensis guyanensis: this supports their taxonomic status as distinct species. In contrast, only slight mobility differences of four enzymes (ASAT, ALAT, PGM, MPI) separate L. b. braziliensis and L. b. guyanensis, which are distinguished biochemically for the first time: this indicates that they are closely related. Four stocks of L. b. panamensis correspond with L. b. guyanensis on mobilities of 10 enzymes (ASAT, ALAT, PGM, GPI, G6PD, MDH, PK, HK, MPI, ACP), although these two subspecies are known to be separable by kinetoplast DNA buoyancies and the enzyme 6PGDH. The generation of practical, regional biochemical keys to the medically important leishmanias is discussed.

A histological classification of mucocutaneous leishmaniasis in Brazil and its clinical evaluation

Biopsies of skin and mucosal lesions were made on 60 well documented Brazilian patients with untreated cutaneous or mucocutaneous leishmaniasis, whose response to treatment was subsequently evaluated in 38 cases. The biopsies were examined with a view to classification after correlation with clinical and immunological findings. Although there was no simple or unified spectrum, five histological groups were defined and found to have some clinico-prognostic significance. In two groups the cases were all cutaneous with a relatively good prognosis. In another two groups they were evolving as mucocutaneous with a poor prognosis. The fifth group showed mixed characteristics with a tendency to relapse. There was no strong correlation with serum antibodies or Montenegro skin test, which were usually positive, or with parasite load, which was always low. The tissue response was distinguished from that in oriental sore by the degree of connective tissue involvement in all groups. It was the primary response in two groups, and subsidiary to a mono-nuclear response in the others. It suggested damage due to extra-cellular parasites or immune complexes. It did not correlate with the distinction between cutaneous and mucocutaneous disease. The single, most favourable, prognostic feature in either the cellular or connective tissue component was necrosis with a reactive response.

Nifurtimox in the treatment of South American leishmaniasis

A trial of Nifurtimox (Lampit) in 26 patients with mucocutaneous leishmaniasis is reported. 13 patients with cutaneous lesions and 13 patients with mucosal disease were treated with a daily oral divided dose of 10 mg/kg body-weight for 30 days. 46% of the cutaneous cases and only 15% of the mucosal cases apparently responded to this regimen during at least one year of follow up. The difficulties of assessing cure in this disease are briefly discussed. We consider that Nifurtimox remains an investigational drug. While possibly exhibiting some anti-leishmanial activity it cannot be recommended for routine use in either form of the disease.

A form of muco-cutaneous leishmaniasis in the Old World

Four Ethiopian patients with leshmaniasis affecting the nose or the mouth are described. Leishmaniasis affecting these sites is relatively common in Ethiopia; this resembles South American leishmaniasis but probably results from direct extension from skin lesions rather than from metastatic spread of organisms.