leish clinicaldrmesfin
DESCRIPTION
TRANSCRIPT
![Page 1: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/1.jpg)
Cutaneous leishmaniasis due to
Leishmania aethiopicaClinical presentations & complications
Mesfin Hunegnaw, MD
July 2011, Addis Ababa
![Page 2: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/2.jpg)
Leishmania aethiopica
• It is the dominant species causing Cutaneous
leishmaniasis (CL) in Ethiopia
• Clinical subtypes:
- Localized CL
- Mucocutaneous
- Diffuse
![Page 3: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/3.jpg)
Localized cutaneous leishmaniasis
Incubation period variable, usually several weeks
Infection may be subclinical or clinical
Subclinical cases may manifest with immunosuppression
Primary lesion may be patch of erythematous induration at
site of sandfly bite
Progresses to papulonodular, plaque or ulcerative lesion
![Page 4: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/4.jpg)
Localized cutaneous leishmaniasis
When it ulcerates it forms central depression and
raised indurated border
Nodules plaques or ulcers may enlarge to assume a
diameter of several centimeters
May persist for months or years before eventually
healing with an atrophic scar
Many lesions do not ulcerate but persist as nodules or
plaques
![Page 5: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/5.jpg)
Localized cutaneous leishmaniasis
Some patients have more than one primary lesion
Lesions are not always well-defined
Because of lymphatic spread, may get:
Satellite lesions
Sporotichoid spread
Local lymphangitis
Local lymphadenopathy
![Page 6: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/6.jpg)
2 large lesions, both poorly defined. Only showed partial response to parenteral antimonial at end of 2nd cycle
![Page 7: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/7.jpg)
Inadequate treatment resulting in leishmaniasis recidivans: This will now be difficult to treat
![Page 8: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/8.jpg)
HIV co-infection
• As large as 5.6% co-infection rate (report from Tigray)
• Clinical presentations are
– Atypical
– Severe
– ↑ risk diffuse & mucocutaneous involvement
– Poor responses to standard therapy
– Higher relapse rate
![Page 9: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/9.jpg)
Diffuse cutaneous leishmaniasis
• L. aethiopica
• Initial lesion may be small and well-defined
• Then multiple nodular & infiltrative lesions may appear
• Resembles lepromatous leprosy
• Lesions occasionally ulcerate and scar causing deformity
• Diffuse CL may appear months/years after initial lesion healed
• Poor CMI: Lesions are laden with parasite
• Poor treatment responses & high relapse rate
![Page 10: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/10.jpg)
Diffuse CL very disfiguring and treatment unresponsive
![Page 11: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/11.jpg)
![Page 12: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/12.jpg)
Ulcerative DCL
![Page 13: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/13.jpg)
Ulceration, Contracture and deformity of the fingers
![Page 14: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/14.jpg)
Extensive scaring, deformity & contractures
![Page 15: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/15.jpg)
Mucocutaneous leishmaniasis
• Causative agent is L. aethiopica• Occurs from lymphatic spread of amastigote • Mucosal infection can occur in the presence or absence of
the primary • Primary lesion may be adjacent to nostril or anywhere on
the face• Often significant facial lymphodema because of rich facial
lymphatic supply• The early symptoms of mucosal infection:
• nasal congestion • epistaxis
![Page 16: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/16.jpg)
Mucosal spread with lesions Naso-pharinigeal area
![Page 17: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/17.jpg)
Spread of facial lesion to lower lip mucosa with oedema
![Page 18: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/18.jpg)
Mucosal spread with severe facial lymphoedema developed one year after scar healed
![Page 19: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/19.jpg)
Scarring from previous lesions. Patient now complains of nasal stuffiness & epistaxis
![Page 20: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/20.jpg)
Untreated facial lesion self-healed. Patient now has mucosal disease affecting lips
![Page 21: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/21.jpg)
Although lesion is defined patient is c/o of nasal congestion
![Page 22: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/22.jpg)
Mucocutaneous leishmaniasis
• Lesions can be destructive: nasal septum & other cartilaginous
structures
• How great is the risk of inadequately treated CL progressing to
mucosal disease? Difficult to assess:
- Because of severe stigma, patients are isolated in home & villages and
do not seek treatment
- May be due to culture, the patients do not return to same clinician
when there is disease recurrence. They seek treatment elsewhere
![Page 23: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/23.jpg)
HIV -ve. Lesions still very active. c/o epistaxis
![Page 24: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/24.jpg)
HIV positive. Palate also affected
![Page 25: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/25.jpg)
HIV -ve. Previously healed facial lesions with scarring. Active mucosal disease
![Page 26: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/26.jpg)
Also has active lesions over hands associated with severe scarring and deformity
![Page 27: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/27.jpg)
Goals of therapy
• Accelerate healing• Minimize scarring• Prevent complications• Prevent disease progression• Decrease risk of relapse
![Page 28: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/28.jpg)
Antimonials
• Have efficacy against L. aethiopica
• Localized lesions respond well
• Established MCL or diffuse leish respond poorly
• Aim of treatment should be;
- Clinical & parasitological cure
- To prevent any risk of disease progressing to MCL or diffuse
leishmaniasis as cure will be difficult/ impossible
![Page 29: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/29.jpg)
Summary
• L. aethiopica is not a benign species
• Severe disease is probably underestimated as stigma might
cause social isolation
• We have seen cases of facial lesions which have
‘metastasized’ to mucosa
• Significantly associated lymphodema suggests lymphatic
spread
• DCL may manifest many years after single lesion has healed
![Page 30: Leish clinicaldrmesfin](https://reader036.vdocument.in/reader036/viewer/2022070302/5477a112b4af9f40718b46ee/html5/thumbnails/30.jpg)