The current clinical and geographical situation of cutaneous leishmaniasis based on species identification in Turkey

Leishmaniases are a group of vector-borne diseases caused by the members of Leishmania genus, and there are three main clinical forms of the infection as visceral, cutaneous, and mucocutaneous. Cutaneous leishmaniasis is a growing public health problem in Turkey due to increasing detection of autochthonous cases caused by L. major and L. donovani in some regions in addition to Syrian imported cases. For this reason, we aimed to evaluate the current epidemiological situation of CL in the view of causative agents and their geographical distribution throughout Turkey. The samples were collected from 356 CL patients admitted to different centers in 18 provinces between January 2013 and December 2016. Direct microscopy, culture (regular and enriched NNN) and molecular techniques (real-time ITS1 PCR and hsp70 PCR/sequencing) were performed. By molecular techniques, 299, 28, 19 and 10 isolates/clinical samples were identified as L. tropica, L. major, L. infantum and L. donovani, respectively. Most of the patients (65.73%) had one lesion usually on their face/head. Dry-nodular type lesions (n = 291) were mainly associated with L. tropica while L. major was mainly found related to wet-ulcerative ones. Leishmaniasis recidivans was also detected in 2.52% among 356 patients. L. tropica was detected as most widespread species causing CL in Turkey. L. infantum and L. major was also found in one third of the provinces. Enriched NNN culture was worked well for isolating the parasite and 346 isolates were successfully grown and stored in liquid nitrogen. The comparison of all diagnostic techniques showed that the parasitological positivity rate could increase if the combination of direct microscopy and real-time ITS1 PCR is used. Besides well-known anthroponotic L. tropica cases, the increasing detection of CL cases caused by zoonotic species, L. infantum and L. major, is one of the most important findings in the present study. In our opinion to ensure timely and accurate diagnosis, proper treatment and countrywide effective control of CL in Turkey a systematic approach is needed on the base of information about characteristics of lesions and patients and epidemiological features of the disease.

The Value of Etiological Tests and Skin Biopsy in the Management of Prurigo Simplex Subacuta

It has been emphasized that prurigo simplex subacuta may be associated with various disorders and may be clinically confused with dermatitis herpetiformis. Aim of the study was to evaluate the value of our set of tests for finding possible associations and for the aforementioned differential diagnosis. Rates of implementations and abnormal results in our set of tests, including skin prick test, skin biopsy, complete blood count, blood chemistry panel, and psychiatric evaluation were analyzed retrospectively between the years of 2010 and 2015 in 130 patients clinically diagnosed with prurigo simplex subacuta. The set of tests was implemented completely in 43.8% patients and with only a single missing test in 31.5% of the patients. The least implemented procedure was psychiatric evaluation (66.9%). The most commonly found issues were psychiatric abnormalities (55.2% of 87 psychiatrically evaluated patients) and atopy (53.8% of 104 skin prick tested patients). The most common finding suggestive of internal diseases was hyperglycemia (25.4% of 130 patients). It was a striking result that hematological malignancies were suspected upon complete blood count and peripheral blood smear and confirmed by further investigations in 4 of 102 patients. Dermatitis herpetiformis was diagnosed in 2 of 120 skin biopsied patients. Because of the substantial rate of implementation, the high frequencies of psychiatric abnormalities and atopy, and detection of hematological malignancies and dermatitis herpetiformis even in just a few patients, we recommend our set of tests for patients clinically diagnosed as prurigo simplex subacuta.

Leishmaniasis in Turkey: first clinical isolation of Leishmania major from 18 autochthonous cases of cutaneous leishmaniasis in four geographical regions

OBJECTIVE

To report isolation of Leishmania major strains obtained from 18 Turkish autochthonous cutaneous leishmaniasis (CL) patients infected with L. major between 2011 and 2014.

METHODS

Initial diagnosis relied on microscopy and culture in enriched medium, prepared by adding specific amounts of liver extract, protein and lipid sources to NNN medium. Promastigotes were then transferred to RPMI medium including 10% of foetal calf serum for mass culture. Species-specific real-time PCR targeting ITS1 region of Leishmania spp. was performed using both lesion aspiration samples and cultured promastigotes. Two of 18 isolates were identified by isoenzyme analysis in the Leishmaniasis Reference Center in Montpellier, France. Each isolate was inoculated into the footpads of six mice to observe the pathogenicity of L. major. Developing lesions were observed, and the thickening of footpads was measured weekly.

RESULTS

Melting curve analyses of 18 isolates showed a peak concordant with L. major, and two of them were confirmed by isoenzyme analyses as L. major zymodeme MON103. In the mouse model, acute lesions seen on day 21 were accepted as an indication of heavy infection. Severe impairments were observed on all mouse footpads over 3 weeks, which even progressed to extremity amputation.

CONCLUSION

Cutaneous leishmaniasis-causing L. major was recently identified in Adana province in southern Turkey, with PCR. Our study shows that such CL cases are not limited to Adana but currently present from western to Southeastern Anatolia, and along the Mediterranean coast. The role of small mammals, the main reservoirs of L. major in Anatolia, needs to be elucidated, as do the underlying factors that cause severe clinical manifestations in L. major infections in Turkey, contrary to the infections in neighbouring countries.