leishmaniasis. haris bela
TRANSCRIPT
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.