Co‐infection of mucosal leishmaniasis and extra pulmonary tuberculosis in a patient with inherent immune deficiency

Background In Sri Lanka, cutaneous leishmaniasis is a well‐established disease caused by Leishmania donovani. Only a few cases of visceral disease and mucosal localization have been reported to date. Case report A 52‐year‐old man presented with severe local destruction of his upper and lower lip and total destruction of the anterior nasal septum and was diagnosed with mucosal leishmaniasis. The causative organism was confirmed to be Leishmania donovani. In addition he had tuberculous lymphadenitis and inherent immune deficiency. His previous medical history was unremarkable. The patient was successfully treated with intramuscular sodium stibogluconate. Conclusion The clinical picture and satisfactory treatment response to antimony are similar to mucosal leishmaniasis caused by L. donovani reported in India and Sudan and with the absence of primary skin lesions make it different from new world mucosal leishmaniasis. Even though leishmania and tuberculous co‐infection has been reported in association with HIV this has not been reported in inherent immune deficiency.     

Old World eyelid cutaneous leishmaniasis: a case report

Leishmania is a protozoa that may infect the skin, mucous, and viscera. The geographical distribution of cutaneous leishmaniasis (CL) is mainly determined by the sandfly vectors. The Old World type is mainly attributed to Leishmania major and Leishmania tropica, and in South of Europe only to Leishmania infantum. A 63-year-old woman, who noted a pimple on the external third of the left upper eyelid 6 months before. The lesion was nodular, well-defined and measured 1.1 cm in diameter and in height, simulating a basal cell carcinoma. It was surgically excised. CL diagnosis was made upon the histologic examination, which showed histiocytes with intracellular leishmania organisms. At 2 years followup, no evidence exists of cutaneous, mucous, or visceral involvement. Apart from carcinomas, nodular lesions with central ulceration are rare on the eyelid. A single cutaneous lesion of leishmania (oriental sore) has to be considered in the differential diagnosis, along with malignant eyelid neoplasms.     

Cutaneous leishmaniasis in a Senegal patient

Cutaneous leishmaniasis is a group of diseases with vast clinical polymorphism produced by protozoa of the genus Leishmania, that is acquired through the bite of sandflies. It is an endemic zoonosis in Spain, being the dog the main reservoir. In our country all forms of leishmaniasis are due to Leishmania infantum species, that usually produces mild lesions in uncovered areas, mainly in children. We report an imported case of cutaneous leishmaniasis in a Senegal patient that presented clinical characteristics unusually different from the typical lesions produced by L. infantum that we are used to evaluate. The lesions were multiple, large, very inflammatory and exudative; these differences may be attributed to the type of endemic leishmania in Senegal: L. major. Given the increase in immigrant population and travels abroad, it is essential for the dermatologist to become familiar with skin diseases of tropical areas that, in the near future, will be more common in daily clinical practice.     

Unusual clinical variants of cutaneous leishmaniasis in Sicily

Background  The term "leishmaniasis" defines a group of vector-borne diseases caused by species of the genus Leishmania and characterized by a spectrum of clinical manifestations. Parasite properties (infectivity, pathogenicity, virulence), host factors, and host responses regulate heterogeneous disease expression. Sicily is one of the major islands of the Mediterranean Basin and is considered to be a hypo-endemic area for cutaneous leishmaniasis. Leishmania infantum is the most common species on the island.
Methods  Fifty patients (both sexes and different ages) with lesions clinically suggestive of cutaneous leishmaniasis were recorded over a 1-year period. The diagnosis was based on positive slit-skin smear and histopathologic studies when needed. Polymerase chain reaction (PCR) was performed as test confirmation.
Results  Twenty-five patients had typical solitary lesions of cutaneous leishmaniasis. Multiple lesions were present in five patients. In 20 patients, the lesions were very unusual, including erysipeloid, zosteriform, and lupoid leishmaniasis. The results of Leishmania isoenzyme characterization identified Leishmania infantum as the species responsible for the 20 atypical cases.
Conclusion  The global number of cases of cutaneous leishmaniasis in Sicily has increased in recent years, and such increases can be explained, in part, by the fact that, in this region, sandflies are present during a large part of the year. This is a result of the climatic variation in recent years (increasing temperature and humidity). There has also been an increase in the number of new and rare variants of cutaneous leishmaniasis. A knowledge of the unusual clinical variants of cutaneous leishmaniasis, as well as classical forms, allows early detection.     

Cutaneous leishmaniasis

Leishmaniases are diseases caused by infection by protozoa of the genus Leishmania. Cutaneous leishmaniasis caused by Leishmania infantum is frequent in Spain, especially in certain geographic areas. Diagnosis of cutaneous leishmaniasis is difficult because of the varied symptoms and because making cultures of this parasite is complicated. There are also different therapeutic, medical and surgical options, none of which is fully satisfactory. We review the most significant agents of cutaneous leishmaniasis in Spain.     

Primary Leishmania infantum MON-80 endonasal leishmaniasis in Tunisia

BACKGROUND: Mucocutaneous leishmaniasis is endemic in Central and South America. It causes massive mutilating and disfiguring lesions and can lead to destruction of facial structures. In Tunisia, leishmaniasis of the mucous membranes is rare, usually developing as a complication of cutaneous leishmaniasis via direct extension. We report the first case in Tunisia of isolated and primary nasal leishmaniasis. CASE REPORT: A 70-year-old man with a history of nephrectomy for renal lithiasis was seen with a painless nodule that had been present for one month. The latter was erythematous, polypoid and firm, with a diameter of 2 cm, and was situated in the right endonasal mucosa. The diagnosis of leishmaniasis was confirmed by histological and direct examinations revealing high numbers of amastigotes of Leishmania. Culture of the offending organism in NNN medium and isoenzymatic characterization resulted in identification of MON-80 Leishmania infantum leishmaniasis. The outcome was good with treatment, and the nodule was deflated after six months. DISCUSSION: There have been few reports of similar cases of primary and isolated mucosal leishmaniasis caused by Leishmania infantum. Our case is also unusual in that zymodeme MON-80 is only rarely a cause of Mediterranean leishmaniasis.     

Leishmania infantum/HIV co-infection: cutaneous lesions following treatment of visceral leishmaniasis

BACKGROUND: The Mediterranean basin is an endemic region of leishmaniasis caused by Leishmania infantum. With the advent of human immunodeficiency virus (HIV) infection, the number of cases of visceral leishmaniasis has dramatically increased in this area over the last years, mainly in adults. Moreover, the presence of cutaneous lesions infested with Leishmania has been frequently reported in these patients. CASE-REPORT: A 35-year-old Portuguese woman, a former intravenous drug user HIV1-positive since 1997, developed visceral leishmaniasis in 2000, with several relapses in 2001 and 2002, treated successively with pentavalent antimonial salts (Glucantime), liposomal amphotericin B and Glucantime associated with itraconazole. Several weeks after therapy for the second relapse of visceral leishmaniasis, physical examination revealed asymptomatic erythematous papules on the face that later spread to the trunk and upper limbs. Histopathologic studies of a skin biopsy revealed a granulomatous infiltrate in the dermis with the presence of Leishmania amastigotes. After culture, the parasite was identified as L. infantum MON-1. In spite of improvement of the patient's visceral leishmaniasis with the above-mentioned treatment, the cutaneous lesions became increasingly numerous and infiltrated. After 2 months of therapy with intravenous pentamidine (4 mg/kg/3 times a week) and oral dapsone (100 mg b.i.d), the cutaneous lesions disappeared completely. Prevention with dapsone was successfully maintained for 6 months. Several weeks after discontinuation of treatment, further lesions appeared. The patient improved again on reintroduction of dapsone. DISCUSSION: This case confirmed the existence of a clinical form similar to post-kala-azar dermal leishmaniasis in a patient co-infected with L. infantum MON-1/HIV. The cutaneous lesions were resistant to classical antileishmanial drugs but disappeared on treatment with dapsone.     

Cutaneous leishmaniasis due to Leishmania major involving the bone marrow in an AIDS patient in Burkina Faso

BACKGROUND: Leishmaniasis covers three well-individualized clinical variants, each due to individual species found in different geographic areas. Herein we report the first case of cutaneous leishmaniasis due to Leishmania major involving bone marrow in an AIDS patient in Burkina Faso. CASE REPORT: A 38-year-old HIV-positive man presented with generalized, copper-coloured, painless, infiltrated, itching, papulonodular lesions present over the previous 10 months. Skin biopsy confirmed the diagnosis of diffuse cutaneous leishmaniasis. The bone-marrow smear showed numerous leishmania. The culture was positive and L. major was identified. The patient was being treated with antiretroviral medication and a pentavalent antimonial compound. The disease progression consisted of attacks and remissions separated by an average of three weeks. DISCUSSION: L. major is the Leishmania species identified in Burkina Faso. It is responsible for typical cutaneous leishmaniasis but particular clinical forms have been described in immunodeficient patients, especially with diffuse cutaneous involvement. The spread of L. major infection to bone marrow could represent a public health problem in our country, where the HIV epidemic is still not under control, and particular vigilance is thus called for.     

Cutaneous leishmaniasis

Infections with Leishmania are increasing worldwide because of tourism and job-related travel; central Europe is no exception. Infections often first become apparent after return from an endemic region. Depending on the Leishmania species and the host immune status, different forms of cutaneous (CL), mucocutaneous (MCL) (L. brasiliensis complex) or visceral leishmaniasis (L. donovani as well as L. infantum) may develop. CL may heal spontaneously with scarring but can evolve into diffuse CL (with reduced immune response to L. amazonensis, L. guyanensis, L. mexicana or L. aethiopica) or into recurrent CL. Diagnostic criteria include travel to an endemic area as well as ulcerated plaques or nodules on an exposed site which show no tendency towards healing over 3-4 weeks. Differential diagnostic considerations include ecthyma, other infectious ulcers, and malignant neoplasms. The diagnosis is confirmed by finding Leishmania in a smear or tissue biopsy, as well as by culture. Therapy options range from topical treatment of simple CL of the Old World caused by L. major to systemic therapy which is needed for most complex cases of CL as well as MCL. Miltefosine is a less toxic option to replace the antimony compounds.     

Dermatofibroma parasitized by Leishmania in HIV infection: a new morphologic expression of dermal Kala Azar in an immunodepressed patient

Visceral leishmaniasis is a protozoan infection that may complicate the course of patients with human immunodeficiency virus (HIV). Dermatofibroma is a cutaneous fibrohistiocytic lesion considered neoplastic by some authors and inflammatory by others. Eruptive dermatofibromas have been described in patients with HIV infection or with other altered immunity situations. We present the case of a 32-year-old, HIV-positive man with visceral leishmaniasis who complained of the appearance of a cutaneous lesion in the leg formed by the coexistence of dermatofibroma and Leishmania parasitic colonization. As far as we know, this type of association has not been reported previously. We consider that the dermatofibroma could have developed as an unusual form of fibrohistiocytic reaction to leishmania. From a practical approach, we recommend the search of leishmaniasis in dermatofibroma in immunosuppressed patients.     

Unusual manifestations of tegumentary leishmaniasis in AIDS patients from the New World

Background  Comorbidity from tegumentary leishmaniasis and AIDS is poorly characterized.
Objectives  To describe a series of patients coinfected with Leishmania and human immunodeficiency virus (HIV).
Methods  Clinical records from patients were analysed by demographic data, clinical manifestations, diagnoses, treatments and outcomes.
Results  Fifteen cases of AIDS/tegumentary leishmaniasis were found. The diagnosis of leishmaniasis was confirmed by the detection of Leishmania amastigotes or antigens from the cutaneous or mucosal lesions. The mean CD4+ T-cell count was 84 cells mm⁻³ (range 8–258) and all patients were classified as having AIDS according to the Centers for Disease Control and Prevention. A wide range of manifestations was found, varying from a single ulcer to multiple and polymorphic lesions. Mucosal lesions were present in 80% and cutaneous lesions in 73% of patients (53% with mucocutaneous form), disseminated lesions in 60% and genital lesions in 27% of patients. All patients received anti- Leishmania therapy and 53% showed relapses. Sixty-seven per cent received highly active antiretroviral therapy but showed no difference in outcomes and relapses compared with those not using medication. Forty per cent died during the study period. In these patients, the anti- Leishmania antibody and Montenegro skin test were useful in the diagnosis of leishmaniasis, probably because leishmaniasis preceded immunosuppression due to HIV infection.
Conclusions  Clinical manifestations of tegumentary leishmaniasis in HIV-infected patients are diverse. Our data emphasize possible unusual manifestations of this disease in HIV-infected patients, particularly in severely immunosuppressed cases (< 200 CD4+ cells mm⁻³).     

Ulcerated disseminated cutaneous leishmaniasis associated with vitiligo, hypothyroidism, and diabetes mellitus in a patient with Down syndrome

We report a 35-year-old man who was referred to our dermatology department with multiple, nodular, ulcerated, and crusted lesions disseminated on the face, trunk, and extremities. He has a known diagnosis of Down syndrome. The past medical history also included vitiligo (for 20 years), hypothyroidism (for 2 years), and type-II diabetes mellitus (for 3 months). Direct smear of an ulcer was positive for leishmania. Skin biopsy confirmed the diagnosis. A leishmanin skin test was negative. Polymerase chain reaction (PCR) from two separate skin biopsies demonstrated the presence of Leishmania major. To our knowledge, this is the first report of disseminated cutaneous leishmaniasis (DCL) caused by L. major in Iran, and also the first report of association between DCL with Down syndrome, vitiligo, hypothyroidism, and diabetes mellitus.     

Treatment of cutaneous leishmaniasis with 20% paromomycin ointment

Cutaneous leishmaniasis is an infectious disease caused by flagellate protozoa of the genus Leishmania. In Mediterranean countries, the most common causative agents are Leishmania (L.) major, L. infantum and L. tropica. In Croatia, cutaneous leishmaniasis is a rare disease, the last case being reported in 1988. Our patient was a 5-year-old boy with a left cheek skin lesion in the form of papule with central exulceration, hyperkeratotic crust and erythema of a 6-month duration. The diagnosis of cutaneous leishmaniasis was based on history data (stay in the southernmost region of Croatia and multiple mosquito bites), light microscopic histology (dense infiltrates of large histiocytes with extracellular bodies), and positive Montenegro (leishmanin) test. A new therapy with aminosidine (paromomycin), an aminoglycoside antibiotic, in the form of ointment at a concentration of 20%, was for the first time used in Croatia. Four-week therapy resulted in complete regression of the skin lesions with residual hyperpigmentation. During therapy, no local or systemic side effects were observed. Thus, topical therapy with paromomycin could be considered an efficient therapeutic alternative in the management of cutaneous leishmaniasis.     

Nodular lymphangitic subcutaneous dissemination after intralesional antimonial treatment for localized cutaneous leishmaniasis

Human leishmaniases are protozoan diseases with diverse clinical features. They are transmitted by the bites of the Phlebotomus sand fly, and the reservoirs are usually wild and domestic animals, particularly dogs. In Spain, Leishmania infantum is the causative agent of both cutaneous and visceral leishmaniasis. Cutaneous leishmaniasis is a parasitic disease occurring throughout the Americas and in the Old World, particularly the Middle East and North Africa. It is spread by the female sandfly. We report a 33-year-old man who presented with a solitary plaque on the right elbow, which was found to contain Leishmania bodies. He was treated with intralesional meglumine antimoniate, but 2 weeks later, several subcutaneous nodules were noted on the inner right arm. PCR identified the organism as L. infantum. The patient was treated with itraconazole (200 mg/day) for 6 weeks was prescribed, which resulted in marked clinical improvement in the elbow plaque. However, because of the persistence and lack of response of the other lesions, systemic treatment with meglumine antimoniate (20 mg/kg/day) intravenously for 7 days and intramuscularly for 13 days was administered. A progressive improvement in both cutaneous and subcutaneous lesions was achieved, and the lesions resolved completely after 2 months.     

Leishmaniasis as an emerging infection

Leishmaniasis is a protozoan disease whose diverse clinical manifestations are dependent both on the infecting species of Leishmania and the immune response of the host. Transmission of the disease occurs by the bite of a sand fly infected with Leishmania parasites. Infection may be restricted to the skin in cutaneous leishmaniasis, limited to the mucous membranes in mucosal leishmaniasis, or spread internally in visceral leishmaniasis or kala azar. The overall prevalence of leishmaniasis is 12 million cases worldwide, and the global yearly incidence of all clinical forms approaches 2 million new cases (World Health Organization WHO/ LEISH/200.42, Leishmania/HIV Co-Infection in Southwestern Europe 1990-98: Retrospective Analysis of 965 Cases, 2000). In the last two decades, leishmaniasis, especially visceral leishmaniasis, has been recognized as an opportunistic disease in the immunocompromised, particularly in patients infected with human immunodeficiency virus.     

Cutaneous leishmania in HIV patient in Ouagadougou: clinical and therapeutic aspects

BACKGROUND: Immune suppression cause by HIV infection is a risk factor in the progression of leishmania diseases. In Burkina Faso atypical clinical presentations of leishmaniases have been observed among people living with HIV. The goal of this study was to describe clinical and evolutionary aspects of cutaneous leishmania and HIV co-infection among patients followed at Ouagadougou University Hospital. PATIENTS AND METHODS: This 16-month prospective study was carried out from January 2003 to April 2004 among HIV-seropositive patients with a diagnosed cutaneous leishmania infection. At baseline, infection and lesions were classified. Clinical diagnosis of cutaneous leishmania depended on finding parasites by microscopy in smears or tissue biopsies. Histological examinations were done if clinical and parasitological diagnosis were not concordant. Treatment consisted of three 21-day rounds of pentavalent antimonial, (Glucantime(R)). Clinical evolution was monitored at the end of each treatment round. RESULTS: Thirty-two HIV-1 positive patients (16 women and 16 men) were included. Mean age was 35.5 (10-67 years old). Leishmania lesions had been evolving, on average, for 12 weeks. Eleven patients were taking HAART and 21 patients were taking cotrimoxazole prophylaxis against opportunistic infections. Cutaneous lesions were found: in the face (15 cases), torso (18 cases), upperlimbs (26 cases) and lower-limbs (28 cases). Observed clinical forms were: papulo-nodular (9 cases), ulcerative (14 cases), infiltrative (12 cases), lepromatous and diffuse (15 cases), psoriasis-like (5 cases), cheloid, histioid or kaposi-like (1 case each). Some patients presented more than one clinical form. Prognosis was satisfactory in 24 patients after the first treatment. Twelve patients relapsed after the first treatment, among those 10 were only taking cotrimoxazole. At the end of the third treatment, 24 patients were cured, 3 died and 5 were lost to follow-up. CONCLUSION: Clinical polymorphism of cutaneous leishmania has been observed in HIV-patients, thereby increasing the risk of differential diagnosis.     

Acute New World cutaneous leishmaniasis presenting as tuberculoid granulomatous dermatitis

Acute primary cutaneous leishmaniasis typically presents microscopically with a lymphohistiocytic infiltrate containing admixed plasma cells, parasitized macrophages and abundant organisms. Tuberculoid granulomatous changes may occur in the later phases of primary infection. A 23-year-old male presented 1 month after visiting Peru with classic clinical findings of acute primary cutaneous leishmaniasis, while histopathology showed a tuberculoid granulomatous process that lacked any organisms in hematoxylin-eosin and fungal stains. Polymerase chain reaction (PCR) analysis and tissue cultures confirmed the diagnosis of cutaneous leishmaniasis with Leishmania (Viannia) panamensis infection. A pauci-organism tuberculoid granulomatous process may uncommonly be the presenting histopathology in the acute infectious phase of cutaneous leishmaniasis. Clinicians and dermatopathologists should be aware of this atypical presentation, which may cause diagnostic confusion and delay proper treatment. PCR testing should be employed in cases with high clinical suspicion when histopathology is not definitive.     

Leishmaniasis

Leishmaniasis is a protozoan disease whose clinical manifestations depend both on the infecting species of Leishmania and the immune response of the host. Transmission of the disease occurs by the bite of a sandfly infected with Leishmania parasites. Infection may be restricted to the skin in cutaneous leishmaniasis (CL), to the mucous membranes in mucosal leishmaniasis or spread internally in visceral leishmaniasis (VL). In the last 2 decades, leishmaniasis, especially VL, has been recognized as an opportunistic disease in immunocompromised patients, particularly those infected with HIV. Leishmaniasis is characterized by a spectrum of disease phenotypes that correspond to the strength of the host's cell-mediated immune response. Both susceptible and resistant phenotypes exist within human populations. Clinical cutaneous disease ranges from a few spontaneously-healing lesions, to diffuse external or internal disease, to severe mucous membrane involvement. Spontaneously-healing lesions are associated with positive antigen-specific T cell responsiveness, diffuse cutaneous and visceral disease with T cell non-responsiveness, and mucocutaneous disease with T cell hyperresponsiveness. Current research is focused on determining the extent to which this spectrum of host response is genetically determined. In endemic areas, diagnosis is often made on clinical grounds alone including: small number of lesions; on exposed areas; present for a number of months; resistant to all types of attempted treatments; and usually no pain or itching. Multiple diagnostic techniques are available. When evaluating treatment, the natural history of leishmaniasis must be considered. Lesions of CL heal spontaneously over 1 month to 3 years, while lesions of mucocutaneous and VL rarely, if ever, heal without treatment. Consequently, all the latter patients require treatment. Therapy is not always essential in localized CL, although the majority of such patients are treated. Patients with lesions on the face or other cosmetically important areas are treated to reduce the size of the resultant scar. In addition, the species of parasite should be identified so that infection with Leishmania braziliensis and Leishmania panamensis can be treated to reduce the risk of development of mucocutaneous disease. Treating patients with Leishmania and HIV co-infection requires close monitoring for effectiveness of treatment, especially because of the high relapse rates. Proven treatments include: antimonials, pentamidine, amphotericin B, interferon with antimony. Treatments where current clinical experience is too limited include: allopurinol, ketoconazole, itraconazole, immunotherapy, rifampin, dapsone, localized heat, paromomycin ointment and cryotherapy. Investigational treatments include: WR6026, liposomal amphotericin and miltefosine. In addition, vaccines for leishmaniasis are being investigated in clinical trials.     

DIFFUSE CUTANEOUS LEISHMANIASIS WITH ATYPICAL ASPECTS

A 16-year-old man had long-standing diffuse cutaneous leishmaniasis with the following characteristics: diffuse infiltrated lesions rich in amastigotes, absence of mucosal involvement, and lack of parasite-specific cell-mediated immune response. In situ identification of Leishmania mexicana amazonensis was achieved by the use of monoclonal antibodies. Clinically, as an atypical finding there was deep and extensive ulceration in the lower limbs. Histologically, an atypical characteristic was the presence of a high number of eosinophils in the infiltrate predominantly in the ulcerated lesion. Ultrastructurally, parasitized and lysed eosinophils with dispersion of their granules were seen in the vicinity of parasitized or lysed macrophages.     

Kutane Leishmaniose

Leishmaniasis includes a spectrum of different diseases that differ in their clinical appearance and severity and influence the patient's health to varying degrees. All the diseases are caused by parasites of the genus Leishmania. The simplest and most widely used classifications use the clinical features and the geographic distribution. Cutaneous leishmaniasis can be divided into localized, diffuse, recurrent or post-kala-azar. Using the geographic distribution leishmaniasis of the Old World, is found in Africa, Asia, Middle East, Mediterranean basin and India. Both, cutaneous and visceral leishmaniasis, may develop. In contrast, New World leishmaniasis is caused by leishmania found in Central and South America and cause may cutaneous, mucocutaneous and visceral findings.