First case report of atypical disseminated cutaneous leishmaniasis in an opium abuser in Iran

Sergentomyia species identification and their screening for possible infection to Leishmania spp. in Kaleybar, East-Azerbaijan province, Iran

Leishmaniasis is a protozoal and vector-borne disease. World health organization has considered the disease as a neglected tropical disease. Phlebotomus and Lutzumyia species (order: Diptera, family: Psychodidae) are human leishmaniasis vectors in new and old worlds. Sergentomyia spp. (Diptera, Psychodidae) are proven vectors of lizard leishmaniasis. Although some studies have identified human Leishmania parasites in Sergentomyia, their role in parasite circulation is unknown yet. Hence, the parasitological and molecular methods were used to study the possible Leishmania infection of Sergentomyia spp., in the human and canine visceral leishmaniasis endemic area in North West of Iran. Even though Sergentomyia specimens were caught in a dominant number compared to Phlebotomus spp., no Leishmania promastigote or DNA was detected in live-caught or sticky trap-caught specimens, respectively. Sergentomyia spp. are proven vectors of sauroleishmaniasis, and despite several global reports of Leishmania infection in Sergentomyia spp., such findings should be carefully interpreted to avoid false vector incriminations.

Development of an Indirect Fluorescent Antibody (IFA) Assay for the Detection of Leishmania RNA Virus 2 (LRV2) in Leishmania Parasites

BACKGROUND

Detection of Leishmania RNA virus (LRV) in Old World Leishmania species and their possible role in the disease prognosis requires sensitive and specific methods, preferably independent of the viral genome. We aimed to develop an indirect immunofluorescence antibody (IFA) assay to detect LRV in the Old World Leishmania parasites.

METHODS

Clinical samples were collected from 86 cutaneous leishmaniasis (CL) patients in different endemic areas of CL in Iran, during 2017-2019. For antibody preparation, the viruses were obtained from sediment of an LRV-infected L. major culture-using freeze and thaw cycles followed by gradient cesium chloride centrifugation. The purified viruses were used to immunize a male 3-4 months rabbit. Various dilutions of the LRV-immunized rabbit's serum and a conjugated antibody were deployed to detect LRV in 48 isolates by IFA assay.

RESULTS

LRV virus was detected in four of the 48 CL cases using IFA method. Amplification of a partial fragment of RNA-dependent RNA polymerase (RdRp) gene from the isolates confirmed the IFA results. In phylogeny, the generated RdRp sequences from four isolates were grouped with the other Old World LRVs, but separate from L. aethiopica LRVs, which appeared as a highly supported distinct clade.

CONCLUSION

Further optimization of this approach to detect the LRV directly in lesion scrapings can make it a more reliable tool for field studies and disclosing the virus's possible role in disseminating and unusual clinical features.

Knowledge, attitude, and practices towards cutaneous leishmaniasis in referral cases with cutaneous lesions: A cross-sectional survey in remote districts of southern Khyber Pakhtunkhwa, Pakistan

Background

Cutaneous leishmaniasis is a neglected tropical disease caused by Leishmania spp. and transmitted by female sandflies. Terrorism and counter-insurgency military operations in Federally Administered Tribal Areas (FATA) lead to a large-scale migration of internally displaced persons (IDPs) in Khyber Pakhtunkhwa and thus, new outbreaks of several infectious diseases such as cutaneous leishmaniasis occurred. This study intended to find the prevalence of cutaneous leishmaniasis in people with cutaneous lesions suspected of having cutaneous leishmaniasis in four remote districts of Khyber Pakhtunkhwa and to assess the participant’s knowledge, attitude, and practices about the infection and its control.

Methods

A cross-sectional study was carried out in four remote districts of Khyber Pakhtunkhwa including Karak, Lakki Marwat, Tank, and Dera Ismail Khan (D. I. Khan) and a total of 1,674 participants were recruited using a convenience sampling technique.

Results

The prevalence of cutaneous leishmaniasis among the participants with cutaneous lesions was 50.4% and the infection was comparatively more prevalent in district Karak. Among participants, 56.8% were male and mostly, 53.8% were under the age of 16 years with 52.8% living in kutcha houses and were from rural areas. Multiple skin lesions were more common, and the face was frequently affected body part. The ratio of participants with lesions older than a month was higher and the majority confronted infections with blood protozoan parasites for the first time. Most participants were unaware of the signs/symptoms of the disease, basic knowledge of the vectors, anthroponotic spread, preventive measures, secondary infections, and reservoir hosts. The use of wood/animal dung as fuel, closeness with reservoir animals, and no use of insect repellents were some of the notable risk factors.

Conclusion

Cutaneous leishmaniasis is highly prevalent in the study area and a very low level of awareness was reported among the participants. This study necessitates the planning and execution of regulations and preventive programs, public health education, awareness campaigns, and disease management practices to overcome future incidence of cutaneous leishmaniasis.

Molecular identification of Leishmania RNA virus in cutaneous leishmaniasis patients and rodent reservoirs in Isfahan province, Iran

Leishmania RNA virus (LRV) is a double-strand RNA virus that was first detected in members of the Leishmania viannia in the New World. The present study aimed to investigate the presence of LRV in the Leishmania species isolated from cutaneous leishmaniasis (CL) patients and rodents as reservoirs in Isfahan province an old zoonotic CL focus, center of Iran. Totally, 85 samples were collected from CL patients (n = 80) and rodent reservoirs (n = 5) from different regions of Isfahan province. Species identification was determined using the PCR-RFLP method. Viral dsRNA was extracted and for observation of 5.3 kb dsRNA on an agarose gel. The presence of LRV was surveyed using the Semi-nested PCR method. For phylogenetic analyzes, 6 samples of 13 isolates were sequenced and a phylogenetic tree was drawn by MEGA7 version 7.0.26. Of 80 Leishmania isolates recovered from the patients with CL, 79 and only one were identified as L. major and L. tropica, respectively. Also, the PCR assays detected four L. major and one L. turanica in five assessed Rhombomys opimus as the rodent reservoirs. LRV was detected only in Leishmania species isolated from 13 species of 85 (15.3%) CL including (L. major, n = 12) and (L. tropica, n = 1). Phylogenetic analysis showed that they were belonged to LRV2 and had the highest similarity with Iranian reference LRV2 in GenBank. Our results showed that the LRV2 was present in cutaneous Leishmania species in Isfahan province is the most historical and touristic province of Iran. In the study LRV was not reported from rodent reservoirs, it may be due to the small sample size. Phylogenetic analysis of current sequences demonstrated that these isolates belong to the registered LRV2 of the Old World.

Bionomics and phylo-molecular analysis of Leishmania species isolated from human lesions using ITS1 genes in north-east of Iran

Leishmaniasis is a zoonotic infectious disease caused by Leishmania species. The identification of parasite species and the type of disease is beneficial for treatment and preventive modalities. Leishmania tropica and L. major have been reported as the main etiological agents of cutaneous leishmaniasis (CL) in Iran. The incidence of zoonotic CL has increased and different in distinct loci of Iran. Hence, we perused the Leishmania species and its genetic traits in the North East of Iran. The investigation was conducted on 200 positive smears prepared from patients' lesions suffering from CL referred to the health care centers of northeastern provinces in Iran from 2013 to 2019. The obtained positive microscopy samples were divided to score the ranges from + 1 to + 6, of them 40 smears exhibited low-parasitemia. Leishmania species analyzed using PCR-RFLP, genetic diversity indices evaluation, phylogenetic analysis, and sequencing comparison with other species in the GeneBank based on ITS1 gene. The isolated L. major strains were similar to other Iranian isolates in this region. Pairwise fixation index (F_ST) index was statistically significant in different L. major populations and showed the genetic differences in pairwise population of different geographical locations of Iran. The current study confirmed an old pattern endemicity of zoonotic CL in North-east of Iran. Therefore, in order to assess the hybrid formation, more epidemiological, ecological, and gene polymorphism studies are needed to understand the pathogenic role of Leishmania species in Iran.

Progress of Mucocutaneous Leishmaniasis to Drug Nonresponsive Diffuse Cutaneous Leishmaniasis in Ethiopia. A Case Report

Background

Leishmaniasis is one of the neglected tropical diseases, yet it is associated with high mortality and morbidity. It is caused by intracellular protozoan parasites of the genus Leishmania. Based on the infecting parasite species and host factors, leishmaniasis could be manifested as cutaneous (localized or diffuse), mucocutaneous or visceral clinical forms. In Ethiopia, L. aethiopica is well known to cause all forms of cutaneous leishmaniasis, the localized form being mostcommon.

Case Presentation

An adult patient from Yayu district, west Oromia region of Ethiopia presents with multiple skin lesions on his face, hands and mutilation of nose through both nostrils. Eight years before the present symptoms, he has developed spontaneously healed cutaneous ulcer on his face leaving a permanent scar. Physical examination revealed multiple nodular lesions on his hands, face and nose as well as swelling of the upper lip. Parasitological examination of ulcer lesion revealed presence of amastigotes, and the patient was diagnosed with mucocutaneous leishmaniasis. He was treated with sodium stibogluconate (20 mg/kg/day IM for 30 days) and clinically cured. After two years, he presented with clinical outcomes typical of diffuse cutaneous leishmaniasis. After confirmation by parasitological examination, he was put on sodium stibogluconate (20 mg/kg/day IM for 30 days) and paromomycin (15 mg/kg/day IM for 30 days) combination therapy. As he showed no progress, he was treated with prolonged sodium stibogluconate (20 mg/kg/day IM for 60 days) monotherapy. He was still nonresponsive and discharged uncured.

Conclusion

The present case is unusual in Ethiopia with relapse of mucocutaneous leishmaniasis progressing to diffuse form. The later form was nonresponsive for both mono and combination therapy, therefore, formulating new drugs or evaluating other anti-Leishmania drugs is required.

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.

The Investigation of the Association of Cutaneous Leishmaniasis in Biopsy Specimens of the Patients with Granulomatous Disease and Skin Cancer Using the Molecular Method

Background

Clinically, cutaneous leishmaniasis (CL) can be confused with granulomatous diseases and skin cancers, and it may lead to erroneous diagnosis and treatment. Diagnosis based and histopathology can have some difficulties due to low number of parasites, especially in chronic CL cases. We aimed to emphasize the necessity of considering CL in the differential diagnosis for cases of granulomatous diseases and basal cell carcinoma, particularly in areas where CL is endemic.

Methods

One hundred and seven paraffin-embedded tissue biopsy specimens were selected from the archive, as of 2002, of Pathology Department, School of Medicine, University of Hatay Mustafa Kemal in Hatay, Turkey. After DNA isolation, performed with the samples were used for PCR analysis with specific 13A, 13B primers targeting kinetoplastid DNA (kDNA) found in all Leishmania species. Another PCR was performed with LITSR and L5.8S primers targeting ITS-1 internal-transcribed-spacer-1 (ITS-1) region to subtype positive samples. Then these samples were further analyzed for subtyping with PCR-RFLP using HaeIII enzyme (BsuRI).

Results

Ten out of 107 tissue specimens were positive via kDNA-PCR. Lupus vulgaris, sarcoidosis, skin lymphoma and Leishmania cutis appeared in 9 out of 10 positive specimens. One of the cases presented with a mass on the cheek and was pre-diagnosed with hemangioma, but leishmaniasis did not appear. All of 10 specimens were diagnosed as granulomatous dermatitis. Two out of 10 samples, found positive with kDNA-PCR, were analyzed with ITS-1-PCR and identified as L. infantum/donovani after RFLP.

Conclusion

Molecular methods should be utilized in the differential diagnosis of CL to eliminate false diagnoses of granulomatous diseases and skin cancers.

Climate and climate-sensitive diseases in semi-arid regions: a systematic review

OBJECTIVES

We aim to describe the relationships between climate variables and climate-sensitive diseases (CSDs) in semi-arid regions, highlighting the different main groups of CSDs and their climate patterns.

METHODS

This systematic review considered Medline, Science Direct, Scopus and Web of Science. The data collection period was August and September 2019 and included studies published between 2008 and 2019. This study followed a protocol based on the PRISMA statement. Data analysis was done in a qualitative way.

RESULTS

The most of works were from Africa, Asia and Iran (71%), where temperature was the main climatic variable. Although the studies provide climatic conditions that are more favorable for the incidence of vector-borne and respiratory diseases, the influence of seasonal patterns on the onset, development and end of CSDs is still poorly understood, especially for gastrointestinal disorders. Moreover, little is known about the impact of droughts on CSDs.

CONCLUSIONS

This review summarized the state of art of the relationship between climate and CSDs in semi-arid regions. Moreover, a research agenda was provided, which is fundamental for health policy development, priority setting and public health management.

Mucosal and mucocutaneous leishmaniasis in Iran from 1968 to 2018: a narrative review of clinical features, treatments, and outcomes

Leishmaniases are worldwide zoonotic infectious diseases caused by different types of intracellular protozoan species of the genus Leishmania. Leishmaniasis as an important vector-borne parasitic disease is transmitted between mammalian hosts by female sandflies. There are three main clinical forms of disease with varied severity: visceral leishmaniasis (VL), cutaneous leishmaniasis (CL), and mucocutaneous leishmaniasis (MCL). MCL is the most uncommon form of this syndrome in the Old World. Accordingly, the reports have characterized that patients with the involvement of mucous membranes are rare even in endemic areas. It is well-known that MCL is a rare clinical manifestation in Iran, but there have been several different cases of patients with mucosal (ML) or MCL in some parts of Iran during the past 50 years. Therefore, we aimed to report and present clinical and epidemiological features of ML or MCL in different regions of the country. Also, we demonstrated specified Leishmania species causing the ML in some cases. The present narrative review indicates that ML or MCL is not unexpected in Iran. Based on the findings of the recent studies, it is concluded that diagnosis of ML should be considered by physicians in Iran.

Clinico-Hematological Findings of Acute Pediatric Visceral Leishmaniasis Referred to the Northeast of Iran during 2005-2015

BACKGROUND

To characterize the epidemiological, clinical, hematological and biochemical features of 33 cases hospitalized with pediatric visceral leishmaniasis (PVL) in North Khorasan Province of Iran from 2005 to 2015.

METHODS

The serological, hematological and biochemical tests were employed in 33 children between 8 months to 6 yr with a final diagnosis of acute visceral leishmaniasis (VL). The diagnosis of VL was established by microscopic demonstration of Leishmania spp. amastigotes inactive bone marrow aspiration (BMA).

RESULTS

The most common presenting features were anemia (82.5%), fever (75%), and hepatosplenomegaly (45.4%). Various hematological parameters showed that most patients were suffering from moderate to severe microcytic hypochromic anemia (78.8% had RBC count less than 4 million cells/ul, 67.7% Hb less than 8 fl). 66.7% of them were leukopenic (WBC: less than 5× 10 ³ /μL) and 24.2% had decreased platelet counts. Pancytopenia was observed in 18.2% of cases. MCV, MCH, and MCHC levels were below the reference range in 88%, 90% and 85.1% of the patients respectively. Moreover, aspartate transaminase (AST) and alanine transaminase (ALT) levels were increased in 53.33% and 6.66% of the patients respectively. 92.9% of cases were C-reactive protein (CRP) positive. Bone marrow was found hyper-cellular in all of them, and myeloid to erythroid ratio (M/E) was more than 4 in 39.1% of cases. Plasma cells slightly were increased in 60% of patients and megakaryocytes were decreased in thrombocytopenic patients.

CONCLUSION

Bone marrow/splenic aspiration still remains the gold standard test despite its risk and pain for patients.

Chronic Skin Lesions as the Presentation of Diffuse Cutaneous Leishmaniasis in the HIV-Infected Woman: A Case Report and Review of Literatures

Background:

Cutaneous leishmaniasis (CL) is the most form of leishmaniasis that caused by intracellular parasites, Leishmania.

Case Report:

A 39-year-old woman, known case of HIV infection, presented with a 6-month history of skin lesions initially on her face, then extending onto the chest, abdomen, and extremities. Laboratory examinations revealed leukopenia and a CD4 cell count of 280 cells / mm3. A biopsy was taken from skin lesions, and histopathological studies showed aggregates of macrophages filled with numerous Leishman bodies, the diagnosis of diffuse CL was confirmed. Consequently, she received liposomal amphotericin B (total dose of 40 mg/kg) as a case of diffuse CL. The skin lesions showed significant improvement after completion of treatment.

Conclusion:

Diffuse CL should be considered as a differential diagnosis in all patients with diffuse skin lesions mainly in the cases that suffer from disorders of cell-mediated immunity.