Download - Leish clinicaldrmesfin
Cutaneous leishmaniasis due to
Leishmania aethiopicaClinical presentations & complications
Mesfin Hunegnaw, MD
July 2011, Addis Ababa
Leishmania aethiopica
• It is the dominant species causing Cutaneous
leishmaniasis (CL) in Ethiopia
• Clinical subtypes:
- Localized CL
- Mucocutaneous
- Diffuse
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
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
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
2 large lesions, both poorly defined. Only showed partial response to parenteral antimonial at end of 2nd cycle
Inadequate treatment resulting in leishmaniasis recidivans: This will now be difficult to treat
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
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
Diffuse CL very disfiguring and treatment unresponsive
Ulcerative DCL
Ulceration, Contracture and deformity of the fingers
Extensive scaring, deformity & contractures
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
Mucosal spread with lesions Naso-pharinigeal area
Spread of facial lesion to lower lip mucosa with oedema
Mucosal spread with severe facial lymphoedema developed one year after scar healed
Scarring from previous lesions. Patient now complains of nasal stuffiness & epistaxis
Untreated facial lesion self-healed. Patient now has mucosal disease affecting lips
Although lesion is defined patient is c/o of nasal congestion
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
HIV -ve. Lesions still very active. c/o epistaxis
HIV positive. Palate also affected
HIV -ve. Previously healed facial lesions with scarring. Active mucosal disease
Also has active lesions over hands associated with severe scarring and deformity
Goals of therapy
• Accelerate healing• Minimize scarring• Prevent complications• Prevent disease progression• Decrease risk of relapse
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
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