Clinical study of cutaneous leishmaniasis in the Kashmir Valley

Emerging leishmaniasis in southern Himalayas: A mini-review

Leishmaniasis is a vector-borne parasitic disease affecting millions of people worldwide. However, in the last decade, the number of cases has been reduced from well-documented endemic parts, but sporadic cases have been reported widely from various non-endemic areas, especially from the southern Himalayan zone. This raises concerns about the emergence of new ecological niches. This warrants a critical evaluation of key factors causing this rapid spread and possibly indigenous transmission. This mini-review article is aimed to briefly address the parasite, the vector, and the environmental aspects in the transmission of leishmaniasis in these new foci against a background of worldwide endemic leishmaniasis with a special focus on the southern Himalayan zone. As the lack of knowledge about the causative parasites, vectors, reservoir hosts, atypical presentations, and their management make the problem serious and may lead to the emergence of public health issues. The present works also reviewed the existing information regarding clinical variations, diagnostic methods, treatment, its outcome, and ignite for further research in these aspects of the disease.

A Clinico-Epidemiological Study of Cutaneous Leishmaniasis in a Non-Endemic Region of South Rajasthan

Introduction

Cutaneous leishmaniasis (CL) is a vector-borne protozoal infection of the skin with variable clinical manifestations. In Rajasthan, western Thar desert is endemic for this disease.

Aim

The present study was aimed to describe clinico-epidemiological features of cutaneous leishmaniasis cases from a non-endemic area of South Rajasthan.

Materials and Methods

A hospital-based prospective study was carried out during a period of 3 years (2017-2019). Data regarding clinical profile and treatment outcome were recorded in a predesigned proforma for analysis. Diagnosis of CL was made clinically and confirmed by demonstration of amastigotes in microscopic examination of Giemsa stained tissue smear of lesions.

Results

Out of 24 patients, 16 (67%) were females and 8 (33%) were males. The age ranged from 3 months to 68 years (median-25). Face (67%) and extremities (29%) were the common sites affected. The most common morphological form was crusted plaques (54%) followed by nodular lesions (38%). Slit skin smear for Leishmania donovani bodies was positive in all patients (100%).

Conclusion

This study highlights a focus of CL in non-endemic areas of South Rajasthan. Of late leishmaniasis is breaking out of its classical boundaries and is increasingly being reported from new geographic locations with a possibility of a novel parasite variant. Therefore, a high clinical suspicion of CL should be kept in non-endemic area.

Pediatric cutaneous leishmaniasis: A clinico-epidemiological study from North India

Background:

There has been an upsurge in the cases of cutaneous leishmaniasis over the past few years in the pediatric population of Jammu and Kashmir, hitherto a nonendemic area for the disease., The aim of this study was to describe the clinico-epidemiological profile and therapeutic outcome of pediatric cutaneous leishmaniasis (PCL) over a 10-year period in J and K.

Materials and Methods:

An observational study was conducted at two tertiary care hospitals of Jammu and Kashmir over a period of 10 years (July 2010–June 20). Children presenting to the outpatient department with lesions suggestive of CL were enrolled. Patients suspected of having CL based on clinical criteria were subjected to slit skin smears (SSS) and histopathological examination (HPE) for validation of the diagnosis. Intralesional or systemic sodium stibogluconate (SSG) was the treatment modality used for the management of patients. Clinical follow-up was done at intervals of 2 weeks for the first 2 months and monthly thereafter.

Results:

A total of 376 cases of CL in children aged 1.5–15 years (mean age 8.4 ± 1.4 years) were included in the study. The duration of the disease ranged from 8 to 52 weeks (mean 22.52 ± 1.5 weeks). Lesions were noted mainly on exposed parts of the body, with face being the most commonly affected site (89.0%). Nodulo-ulcerative plaques were the predominant clinical presentation (62.76%). The diagnosis was confirmed by the demonstration of Leishman Donovan (LD) bodies in 54.25% on SSS- and 25.79% on hematoxylin and eosin -stained tissue sections. In cases where diagnosis could not be confirmed by demonstration of LD body, a histological pattern conforming to CL and response to a therapeutic trial of SSG provided evidence of leishmanial infection. Complete healing was achieved in 95.02% of the cases at the end of treatment.

Conclusion:

CL is an emerging health problem in the pediatric population of Jammu and Kashmir. Awareness among pediatric health workers regarding this disease and recognition among the differential diagnosis of ulcerated papules or plaques in the pediatric population is imperative.

Clinical and epidemiological study of cutaneous leishmaniasis in two tertiary care hospitals of Jammu and Kashmir: An emerging disease in North India

BACKGROUND

An increasing number of patients with cutaneous leishmaniasis (CL) are reporting to tertiary care centers in Jammu and Kashmir, an area that has previously been non-endemic for this disease. This merits consideration of CL as a major health problem of considerable epidemiological importance. The aims of this study were firstly to describe the clinico-epidemiological profile, therapeutic characteristics, and outcomes of patients with CL and secondly to highlight this union territory as a new focus of endemicity for CL.

METHODS

A two-center hospital-based prospective cohort study was conducted at two tertiary care hospitals in Jammu and Kashmir over a period of 10 years (July 2009 to June 19). All patients presenting to the outpatient departments with lesions suggestive of CL were enrolled for the purpose of this study. Demographic data were recorded on a proforma questionnaire, along with a detailed history and the results of a meticulous examination. Patients diagnosed with CL based on clinical criteria were subjected to slit skin smear (SSS) and histopathological examination for confirmation of the diagnosis. An intralesional pentavalent antimonial, sodium stibogluconate (SSG), was administered at a dose of 0.5 mL/cm² (100 mg/mL solution) three times weekly to those patients with smaller lesions, and intravenously or intramuscularly at a dose of 20 mg/kg/day to those with larger lesions. The response to treatment was assessed by total re-epithelialization of the lesion and an absence of infiltration and erythema, with or without scarring. Treatment was given until complete resolution of the lesions or for a maximum duration of 10 weeks when given intralesionally and 3 weeks when given systemically. Clinical follow-up was performed twice weekly for the first 2 months and monthly thereafter. The final response to treatment was assessed at 6 months.

RESULTS

The study included a total of 1300 patients with a mean age of 26.7 ± 18.5 years. The mean duration of the disease was 28.52 ± 13.5 weeks, ranging from 8 to 64 weeks. Lesions were noted mainly on exposed parts of the body, with the face being the most commonly affected site (89.00%). Nodulo-ulcerative plaques were the predominant lesion type observed (73.92%). The presence of Leishman-Donovan bodies could be demonstrated on SSS and histopathology in 60.69% and 39.54% of patients, respectively. The presence of a recognizable histological pattern conforming to CL and a response to a therapeutic trial of SSG was considered to be confirmatory in the remaining patients. Complete cure was achieved in 84.23% of cases during the study period. Single lesions were more likely to respond to treatment as compared to multiple lesions. The route of administration did not have any significant impact on the final outcome.

CONCLUSIONS

With the disease showing an escalating trend in Jammu and Kashmir, the possibility of a new focus of endemicity and its impact on public health need to be contemplated, and appropriate measures should be initiated to contain its spread.

Modelling the number of dermal lesions in anthroponotic cutaneous leishmaniasis and its associated factors in Herat province, western Afghanistan, during 2012-2013

Cutaneous leishmaniasis (CL), caused by Leishmania tropica, is the main causative agent of CL in the Herat province, western Afghanistan. In CL patients, one of the most important indicators for reducing the amount of body damage and the choice of treatment is the number of dermal lesions, but there is no strong evidence in this regard. Therefore, using count regression models, the main objective of this historical cohort study was to identify the distribution of the number of dermal lesions and determine the associated factors among CL patients referring to leishmaniasis reference laboratory in Herat province, from January 2012 to December 2013. In a total of 4,127 clinically suspected CL cases, 50.20% were female and 49.80% male. Based on the results of ZINB model, which is the best model suggested by goodness-of-fit criteria, age variables (IRR = 1.007), duration of lesion (6-12 weeks compared to < 6 weeks with IRR = 1.36 and >12 weeks with IRR = 1.39 compared to <6 weeks), type of lesion(both nodule and ulcer compared to papule with IRR = 2.03), location of lesion (trunk with IRR = 1.90, upper with IRR = 1.66, lower with IRR = 1.61 and mix with IRR = 10.35 compared to head/neck/ears) and type of lesion (ulcer compared to papule with IRR = 0.50, nodule and lupoid, respectively, as IRR = 0.72 and IRR = 0.51 compared to papule) had a significant effect on the mean number of dermal lesions (p < .05). Also, our results showed that among four models used, the ZINB model represented a better performance to determine the associated probable factors about the number of dermal lesions in ACL patients. Moreover, there was a direct association between age and number of dermal lesions; in addition, duration of lesion, type of lesion and location of lesion had a significant effect on the number of dermal lesions. Therefore, a comprehensive planning is necessary for controlling and reducing the number of dermal lesions.

[Cutaneous leishmaniasis of the vermilion border of the upper lip extending to the oral mucosa]

BACKGROUND

Cutaneous leishmaniasis is endemic in Morocco. Mucosal involvement is rare. We report a case in Morocco of cutaneous leishmaniasis of the vermilion border of the upper lip extending to the oral mucosa due to Leishmania tropica.

PATIENTS AND METHODS

A 15-year-old girl was seen with 2 ulcerated lesions, present for 4 months, situated on the left cheek and vermilion border and extending to the oral mucosa. The diagnosis of leishmaniasis was confirmed by direct examination revealing high numbers of Leishmania amastigotes. Culture of the offending organism in NNN medium and isoenzymatic characterization resulted in identification of L. tropica. Treatment with meglumine antimoniate (Glucantime) was ineffective. The outcome was good after treatment with fluconazole.

CONCLUSION

In Morocco, cutaneous leishmaniasis with mucosal involvement is rare, and usually develops as a complication of cutaneous leishmaniasis via direct extension.

Atypical leishmaniasis: A global perspective with emphasis on the Indian subcontinent

BACKGROUND

Among the neglected tropical diseases, leishmaniasis continues to be prevalent in many tropical and subtropical countries despite international, national, and local efforts towards its control and elimination over the last decade. This warrants a critical evaluation of such factors as under-reporting, asymptomatic infections, post kala azar dermal leishmaniasis (PKDL) cases, and drug resistance. In this review, we highlight lesser-understood atypical presentations of the disease involving atypical parasite strains against a background of classical leishmaniasis with a focus on the Indian subcontinent.

METHODS AND FINDINGS

A literature review based on endemic areas, the nature of disease manifestation, and underlying causative parasite was performed with data collected from WHO reports for each country. Searches on PubMed included the term ''leishmaniasis" and "leishmaniasis epidemiology" alone and in combination with each of the endemic countries, Leishmania species, cutaneous, visceral, endemic, non-endemic, typical, classical, atypical, and unusual with no date limit and published in English up to September 2017. Our findings portray a scenario with a wider distribution of the disease in new endemic foci, with new discoveries of parasite-driven atypical disease manifestations in different regions of the world. Unlike the classical picture, some Leishmania species are associated with more than one disease presentation, e.g., the L. donovani complex, generally associated with the visceral form, is now also associated with a cutaneous disease presentation, while L. tropica species complex, known to cause cutaneous disease, can cause viscerotropic disease. This phenomenon points towards the discovery of novel parasite variants as etiologic agents of atypical disease manifestations and represents an excellent opportunity to identify and study genes that control disease virulence and tropism.

CONCLUSIONS

The increased recognition of atypical leishmaniasis as an outcome of parasite variants has major implications for leishmaniasis control and elimination. Identifying molecular correlates of parasite isolates from distinct regions associated with different disease phenotypes is required to understand the current epidemiology of leishmaniasis in regions with atypical disease.