Dr.Haris Bela

Patients profile

Name: Sep Nadeem TahirAge:23 yearsResidence: BahawalpurD.O.A: 18/10/10

Presenting Complaints A Painful, discharging wound on tip of nose and

right forearm Itch Progressive increase in size

/01 month

HOPI Past Hx Personal Hx Drug Hx Social Hx NO HISTORY OF ANY

DRUG ERUPTION, ANAPHYLAXIS, ADDICTION !

EXAMGPE VITALS :WNL

Clubbing, lymphadenopathy, cyanosis, pallor, jvp, koilonychia

/ NIL

CVS CNS CHEST GIT

LOCAL EXAMINATION Lesion: HYPERPIGMENTED, BROWNISH

COLOURED NODULAR LESION WITH INDURATION AND OVERLYING PLAQUES AND CRUST FORMATION

At tip of nose 5x5 cm, and at Rt forearm extensor surface 3x3cm

Surrounding skin: Erythema present Mild discharge Borders: slightly raised Consistency: firm

D/D Cutaneous leishmaniasis Tuberculoid leprosy Pyoderma Squamous cell carcinoma Deep fungal infection

Investigations Blood CP Lfts Rfts Urine RE Chest x-ray

WNL

SPECIFIC (histopathological) INVESTIGATIONS

Skin biopsy report Chronic granulomatous inflammation, most

likely due to Cutaneous leishmaniasis. DAB smear: Few LT bodies seen

Final Diagnosis

CUTANEOUS LEISHMANIASIS

Treatment Administered Tab Augmentin 625mg 1xTDS Tab Paracetamol 2xBD Inj Glucantine 10ml I/M OD Polyfax ointment Cryotherapy

CASE DISCUSSION

CUTANEOUS LEISHMANIASIS

Leishmaniasis is a protozoal infection transmitted either zoonotically or anthroponotically, host being human and manifesting in cutaneous or visceral disease depending upon the virulence of infecting species and host’s immune status.

Sand fly

Vector Phlebotomus - Old World Lutzomyia - New World

Reservoirs

Rodents.... L.major Dogs......L.tropica Equines Monkeys Sloths Humans

Zoonotic transmission

Anthroponotic transmission

Incidence and Prevelence

12 million people currently infected worldwide 2 million new cases each year 1.5 million new cases of cutaneous

leishmaniasis 500,000 cases of visceral leishmaniasis. Mucocutaneous leishmaniasis is less

common.

Clinical presentation The 3 primary clinical forms Cutaneous leishmaniasis - self-resolving

cutaneous ulcer Mucocutaneous leishmaniasis - mutilating

mucocutaneous disease Visceral leishmaniasis - lethal systemic

illness

Leishmaniasis is a disease with wide clinical diversity

It results from an interplay between The virulence of the infecting species The host's immune response.

Classification of Leishmaniasis

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Subgenus

Complex Species Main geographic locations Main clinical manifestation Other

Old WorldLeishm

ania

L. donovani

L. donovani

India, sub-Saharan Africa, China, Pakistan Visceral leishmaniasis Post kala-azar dermal leismaniasis (PKDL)

L. infantum*

Mediterranean, Middle East, north and sub-Saharan Africa, Balkans, China

Visceral leishmaniasis  

L. major L. major Middle East, Africa, India, China Cutaneous leishmaniasis ("wet ulcer")

 

L. tropica L. tropica Middle East, India, southern Europe, western Asia Cutaneous leishmaniasis ("dry ulcer")

Leishmaniasis recidivans (LR) and viscerotropic leishmaniasis

L. aethiopica

L. aethiopica

Ethiopia, Kenya, Yemen Cutaneous leishmaniasis Diffuse cutaneous leishmaniasis (DCL)

New WorldLeishm

ania

L. donovani

L. chagasi* Latin America Visceral leishmaniasis  

L. mexicana

L. venezuelensis

Venezuela Cutaneous leishmaniasis  

L. mexicana

Mexico, Central America, Texas, Oklahoma Cutaneous leishmaniasis Diffuse cutaneous leishmaniasis (DCL)

L. amazonensis

Amazon basin, Brazil Cutaneous leishmaniasis Diffuse cutaneous leishmaniasis (DCL). Has also been associated with viceral leishmaniasis.

Viannia L. braziliensis

L. braziliensis

Latin America Cutaneous and mucocutaneous leishmaniasis

 

L. peruviana

Peru and Argentina (highlands) Cutaneous leishmaniasis  

L. guyanensis

L. guyanensis

Northern Amazon basin, Guyanas Cutaneous leishmaniasis  

L. panamensis

Panama, Costa Rica, Columbia Cutaneous leishmaniasis  Organisms belonging to

the subgenus Leishmania develop in the sandfly midgut, whereas organisms belonging to the subspecies Viannia develop in the hindgut. * L. infantum and L. chagasi are now thought to be the same organism.

Cutaneous leishmaniasis

New World - Leishmania mexicana,

Leishmania braziliensis, and Leishmania amazonensis, Subgenus Vianna

Old World - Leishmania tropica, Leishmania major, L infantum, and Leishmania aethiopica

Cutaneous leishmaniasis

1.Localized CL: a. dry/urban/anthrponotic...L.Tropica6months to heal b. wet/rural/zoonotic....L.Major1year to heal c. L.aethiopica on face mostly

Diffuse CL: Patients develop multiple, widespread

cutaneous nonulcerating papules and nodules

relapse is rule Anergic to leishmanin skin testing (LST). Lesions are abundant of parasites Progresses to years

Recidivans cutaneous leishmaniasis A relatively uncommon clinical variant appears as a recurrence of lesions at the site

of apparently healed disease years after the original infection

Typically occur on the face Presents as an enlarging papule, plaque, or

coalescence of papules that heals with central scarring

L.TROPICA

Lesions progression Nodule Crust Ulcer Scar

Basic pathology Inocullum and virulence Macrophages,histiocytes Host Immune response Necrosis and self healing Granulomas

DiagnosisCriteria: History of visit to an endemic area / sand fly

bites Outdoor activity Chronic, nonhealing, voilacious nodular ulcer Lab diagnosis

Diagnostic methods Direct Microscopy: giemsa stained

amastigotes smears Histopath skin sections /scrapings, touch

preparations, slit skin smear : intracellular amastigotes

Skin biopsy : leishmanial granulomas Parasitological cultures :NNN (Nicole-novy-

MacNeal) PCR

LST Leishmanine test

Has been used for decades to determine previous or current exposure to leishmania parasites.

Is not used to distinguish between active and resolved disease, but can be useful in evaluating known naive populations that become immunologically responsive to leishmanial antigens.

Lst is not applicable to immunologically anergic patients with widely disseminated cutaneous disease

Produces positive results 3 months after the appearance of lesions.

test is performed by injecting killed promastigotes intradermally and examining the skin 48 hours later to see if a delayed-type hypersensitivity response has formed.

A positive result is defined as induration of 5 mm or more.

The two main drawbacks are that acute infections cannot be identified (in endemic regions, more than 70% of the population will test positive) since it remains positive for life and those who are immunosuppressed may not mount a response.

The polymerase chain reaction (PCR) is now routinely used in experienced laboratories as a rapid diagnostic technique.

Species-specific PCR probes allow for rapid speciation in confirmed cases of leishmania

Newer methods Parasite speciation:

Cellulose acetate electrophoresis is a well-standardized method for determining the species of parasites grown from clinical samples.

Requires experience and special facilities

Monoclonal antibodies (MoAb) or hybridization of tissue touch blots with labeled kinetoplast DNA probes are used for identification of different strains of Leishmania.

An immunochromatographic strip test exists for rapid detection of antibodies to Leishmania antigen K39.

complications Disability Joint disability Scarring, keloids Progression to MCL or VL

TREATMENT MODALITIES Cryotherapy Local heat application Systemic: pentavalent antimony, antifungals,

paromomycin, pentamidine Topical: paromomycin Intralesional antimony

Sodium stibogluconate Sodium stibogluconate 100 mg/mL diluted 1:2 with

lidocaine 1% (ie, 1 mL sodium stibogluconate plus 2 mL lidocaine); intralesionally, use 2-4 mL q8d, based on clinical response

Cutaneous disease: 20 mg/kg/d IV/IM for 20 d Visceral or mucocutaneous disease: 20 mg/kg/d

IV/IM for 28 d Lesion borders: <1 mg/kg intralesional qwk

Pentamidine Cutaneous disease: 2-4 mg/kg IV/IM once or

twice weekly until lesions resolve

Amebicidal :Paromomycin

Paromomycin has a relatively favorable adverse effect profile, but it is not as effective as antimony or amphotericin B for visceral disease when used as monotherapy. Paromomycin can be used in combination with sodium antimony gluconate to reduce the total time of therapy, and it has better cure rates.

Topical : 15% with methylbenzethonium 12% ( LESHCUTAN)

ANTIFUNGALS The major sterol in both Leishmania organisms and fungi is

ergosterol. Antiergosterol agents, marketed as antifungals, have activity against Leishmania organisms.

Amphoterecin B DOC in antimony-resistant infections (especially if

contracted in India). To reduce renal toxicity (with deoxycholate), several formulations (lipid associated) are used (liposomal [AmBisome], lipid-complexed [Abelcet], colloidal-dispersion [Amphocil] preparations). Least toxic (infusion-related adverse effects) is AmBisome; most

toxic, Amphocil.

Ketoconazole 600mg daily for 4 wks .... L.maxicana

Fluconazole 200mg for 6 wks.... L.major

IMMUNOSTIMULATORS Cytokines Interferon-gamma a T-helper subtype 1

cytokine used to enhance host immunity to Leishmania parasites.

Interferon-gamma-1b (Actimmune) Recombinant DNA product. Administered

with sodium antimony gluconate (probably ineffective alone).

Dosing :100 mcg/m2/d IV for 28 d (with 20 mg/kg/d sodium antimony gluconate)

PREVENTION Protective immunity following medical treatment for infection is 97-98%

effective for disease caused by the same species of Leishmania.

Deliberate scarification (ie, making numerous superficial incisions) of the extremities with material from human lesions was once practiced to prevent facial scarring that might result from a later natural infection.

The treatment of infected persons and elimination of diseased reservoir vertebrates can reduce the source of infection.

Sandfly control (fine-mesh bed netting must be used, because sandflies are small enough to pass through ordinary mosquito netting) impregnated with an insecticide such as permethrin or deltamethrin, and use of insect repellent can prevent disease

Because leishmaniasis can be transmitted through blood, patients who have been infected should not donate blood or organs.

General precautions, such as protective clothing, and minimizing outdoor exposures at peak times (eg, dusk) should also be used.

Current efforts are being made by organizations such as the Tropical Disease Research branch of the World Health Organization and other vaccine initiatives to develop second-generation vaccines against leishmaniasis.