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Hindawi Publishing CorporationJournal of Tropical MedicineVolume 2011, Article ID 359145, 8 pagesdoi:10.1155/2011/359145

Review Article

Clinical Manifestations and Distribution of CutaneousLeishmaniasis in Pakistan

Abaseen Khan Afghan, Masoom Kassi, Pashtoon Murtaza Kasi, Adil Ayub,Niamatullah Kakar, and Shah Muhammad Marri

Department of Pathology, Bolan Medical College, 8-13/36 Kasi Road, Balochistan, Quetta 87300, Pakistan

Correspondence should be addressed to Pashtoon Murtaza Kasi, [email protected]

Received 30 June 2011; Accepted 6 September 2011

Academic Editor: Cristina Riera

Copyright © 2011 Abaseen Khan Afghan et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Cutaneous leishmaniasis (CL) is a rising epidemic in Pakistan. It is a major public health problem in the country especiallyalongside regions bordering the neighboring Afghanistan and cities that have had the maximum influx of refugees. The purposeof our paper is to highlight the diverse clinical manifestations of the disease seen along with the geographic areas affected, wherethe hosts are particularly susceptible. This would also be helpful in presenting the broad spectrum of the disease for training ofhealth care workers and help in surveillance of CL in the region. The increased clinical diversity and the spectrum of phenotypicmanifestations noted underscore the fact that the diagnosis of CL should be not only considered when dealing with commonskin lesions, but also highly suspected by dermatologists and even primary care physicians even when encountering uncommonpathologies. Hence, we would strongly advocate that since most of these patients present to local health care centers and hospitals,primary care practitioners and even lady health workers (LHWs) should be trained in identification of at least the commonpresentations of CL.

1. Background

Cutaneous leishmaniasis (CL) is a rising epidemic in Pakistan[1]. It is a major public health problem in the country es-pecially alongside regions bordering the neighboring Af-ghanistan and cities that have had the maximum influx ofrefugees [2]. Pakistan in particular, as highlighted by Postigo,has been a focus of both anthroponotic cutaneous leishma-niasis caused by Leishmania tropica (L. tropica) and zoonoticCL caused by Leishmania major (L. major) with epidemicsoccurring in various parts of the country [3]. L. tropica ismostly seen in urban areas whereas L. major is more commonin rural areas of the country [4].

The purpose of our paper is to highlight the diverseclinical manifestations of the disease seen along with thegeographic areas affected where the hosts are particularlysusceptible. This would also be helpful in presenting thebroad spectrum of the disease for training of health careworkers and help in surveillance of CL in the region [3].

2. Methodology for Our Review

We searched the terms “cutaneous”, “leishmaniasis,” and“Pakistan,” in Pubmed which retrieved a total of 67 articles.These articles were then systematically reviewed with focuson the number of people affected in different areas of thecountry and the clinical manifestations of the disease doc-umented by the authors. A summary of the studies selectedis outlined in Table 1. References citing other studies donein the region were then also studied for the aforementionedobjectives.

3. Clinical Manifestations ofCutaneous Leishmaniasis

CL is usually noted on exposed parts of the body, mainlyarms, face, and legs. The clinical manifestations are extremelydiverse including unusual sites and atypical morphologies.Typically, the natural course of the lesions seen in CL is

2 Journal of Tropical Medicine

outlined by Figure 1. The lesions typically are not painful,but are associated with significant stigma associated withthe disease (Figure 2). Women and children are particularlyaffected. As noted, however, it is increasingly seen in var-ious unusual forms, for example, as fissures on lips, withlupoid features on face and/or psoriasiform plaques on nose[5, 6]. The myriad of manifestations seen is an outcomeof the interplay between the parasite infection and host’simmune responses [4]. “On one end of the spectrum ofCL is the classical oriental sore in which spontaneous cureand immunity to reinfection is the result of an effectiveparasiticidal mechanism. On the other end of the spec-trum is diffuse cutaneous leishmaniasis in which metastaticcutaneous lesions develop and the patient rarely, if at all,spontaneously develops immunity to the parasite” [7].

4. Causative Agent in Pakistan

The main causative agent noted in our review of the studieswas L. major followed by L. tropica. This was also highlightedin a review on molecular epidemiology of leishmaniasis inAsia, where in southern dry areas of the country, L. major wasseen more often [28]. However, as noted by Katakura as wellas Marco et al., there was no clear association between theskin lesions and the type of leishmaniasis, probably referringto host factors and immunoinflammatory responses beingmore important in determining the type and severity oflesions noted [28–31]. Likewise, no correlation betweenthe type of CL lesions and the causal leishmania parasiteswas noted in a gene sequencing study on samples fromboth provinces of Sindh and Balochistan [14]. However, asoutlined in Table 1, in the same study, there was indeedan association between the type of leishmania parasite andthe altitude of the region, with L. major (97.9%) being thepredominant type of parasite in lowland areas, while L.tropica (76.2%) was more common in highland areas [14]. L.tropica was also the strain most commonly found in a studyfrom Multan and another study with a small sample size fromvarious parts of the country [32, 33]. Clinical presentationsappear to vary by endemic regions [31].

5. Distribution of Cutaneous Leishmaniasisin Pakistan

The country Pakistan is divided into 4 provinces: Punjab,Sindh, Khyber Pakhtunkhwa, and Balochistan along withAzad Jammu Kashmir (AJK). As noted from the researchstudies cited in Table 1, some parts of the country are moreaffected than others (Figure 3).

Balochistan, the largest province by area located in thesouthwest of Pakistan, appears to have taken a significanttoll followed by Khyber Pakhtunkhwa [9]. The geographicdistribution, as noted by Firdous et al., is a function ofthe sandfly vector compounded with activities disturbingtheir habitat including wars as well as deforestation andagricultural activities [4, 34]. Breeding of animals is alsothought to play a contributory role, along with “dark nichesand cracks in the ground providing suitable habitat for thesandflies” [24, 28]. Within Balochistan, areas where most

Red papular lesion

a period of several weeks

and ulcer formation

Healing: atrophy

leading to scar

formation

Incubation period (2 months for L. major)

The papule enlargement then occurs over

Crusting, induration,

Healing: 2–6 months for L. major;

8–12 months for L. tropica infection

Figure 1: Typical sequence of events leading to the formation ofthe typical oriental or “yearly sore” called “kal dana.” Descriptionadopted from excellent review by Arfan u Bari et al., 2009. Picture ofSandflies obtain through the courtesy of Bruce Alexander, ResearchFellow in Molecular and Biochemical Parasitology Group, LiverpoolSchool of Tropical Medicine.

patients have been reported from are Quetta, Ormara, andUthal [35]. Quetta is a metropolitan city and the capital ofthe province. Reasons for more cases of CL being reportedfrom the capital of the province are that people belongingto different castes live there along with many refugees whowere from the adjacent war-torn country of Afghanistan andmigrated during the early 1980s and 1990s [1]. The hospitalsand clinics serve as major teaching/tertiary care centersnot only for the entire province but also for neighboringadjoining areas of Afghanistan.

The increased incidence noted in some parts of thecountry where major teaching hospitals and where most ofthe research studies are conducted may be a function ofbetter awareness and more testing of chronic skin lesionsfor CL. Since a lot of these hospitals and research centerscater and serve as major referral centers for entire provincesin some cases, the true incidence especially in outskirtsand rural areas is currently not exactly known and may bean underestimate [11]. For example, even in the survey-based study of thousands of school children, predominantpopulation affected were male children; the severity and theproportion of women affected may not be entirely knowngiven sociocultural factors [9].

6. The Road Ahead

The increased clinical diversity and the spectrum of phe-notypic manifestations underscore not only fact that the

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n.


(a) (b)

Figure 2: Disfiguring nature of lesions of CL on exposed parts of the body, particularly the face (copyright Kassi et al. [2]). Permission takenunder creative commons attribution license.

18

10, 1112, 13 14, 23

21,22

7

19, 201, 2, 3, 4, 5

9, 16

6, 15

BalochistanSindh

PunjabKhyber Pakhtunkhwa

Figure 3: Distribution of CL in the 4 provinces of Pakistan(numbers represent the studies as noted in the references). As notedin the map as well, the province of Balochistan followed by KhyberPakhtunkhwa appears to have taken a major toll. Most of the citiesand hospitals where the disease has been identified serve as majortertiary care referral centers for the rest of the province. The exactestimates in adjoining cities and rural areas are underestimated andnot well known.

diagnosis of CL should be not only considered when deal-ing with common skin lesions, but also highly suspectedby dermatologists and even primary care physicians evenwhen encountering uncommon pathologies [26]. Diagnosisin these atypical cases, which are now more frequentlybeing seen, can particularly be challenging. Here, we wouldstrongly advocate that since most of these patients presentto local health care centers and hospitals, primary care prac-titioners and even lady health workers (LHWs) should be

trained in identification of at least the common presentationsof CL, since the majority of patients especially in ruralareas do not have access to dermatologists [36]. Providingtraining to LHWs in identification of CL can prove helpfulnot only for women to whom they have access to but also indeveloping better surveillance systems of catching sporadicepidemics early.

A lot of research is being conducted by the efforts oflocal universities themselves and some interventions byNGOs and UNHCR. As noted by Brooker and colleaguesas well, further work and interventions within the countryof Pakistan would have to be supported by the Ministry ofHealth for improving diagnostic abilities and implementingpreventive and treatment programs in more regions of thecountry before the epidemic continues to rise further [13].

7. Conclusions

(i) CL is usually seen in exposed parts of the body.

(ii) The clinical manifestations are extremely diverseincluding unusual sites and atypical morphologies.

(iii) The myriad of manifestations seen is an outcome ofthe interplay between the parasite infection and host’simmune responses.

(iv) The increased clinical diversity and the spectrumof phenotypic manifestations underscore not onlyfact that the diagnosis of CL should be not onlyconsidered when dealing with common skin lesions,but also highly suspected by dermatologists and evenprimary care physicians even when encounteringuncommon pathologies.

(v) Hence, we would strongly advocate that since mostof these patients present to local health care centersand hospitals, primary care practitioners and evenLady Health Workers (LHWs) should be trained inidentification of at least the common presentations ofCL, since the majority of patients especially in ruralareas do not have access to dermatologists.


Acknowledgments

The authors are deeply indebted to the Department ofPathology, Bolan Medical College, for their constant supportand encouragement. The authors declare that they have noconflict of interests.

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