American tegumentary leishmaniasis (ATL) in Rio de Janeiro State, Brazil: main clinical and epidemiologic characteristics

BACKGROUND: Rio de Janeiro State in Brazil is an endemic area of American tegumentary leishmaniasis (ATL) induced by Leishmania (Viannia) braziliensis. Objective Our purpose was to describe the main clinical and epidemiologic characteristics of the disease in Rio de Janeiro State. METHODS: Patients from endemic areas of Rio de Janeiro State attending the Evandro Chagas Hospital were included in the study. A general physical, dermatologic, and otorhinolaryngologic examination was performed in all patients, as well as a Leishmanin skin test. Skin biopsy specimens were obtained and utilized for touch preparations (stained with Leishman dye), culture in special media (Nicolle, Nevy and McNeal; NNN), and histopathologic examination after hematoxylin and eosin stain. Positive cultures were identified with regard to species by the isoenzyme technique. Therapy with pentavalent antimonial compounds was employed in all cases. Eco-epidemiologic characteristics were studied through regular field visits to endemic foci. RESULTS: Cutaneous disease was present in 87.2% of patients, and mucosal disease in only 12.7%. A single ulcerative cutaneous lesion was the most common clinical presentation. Demonstration of the parasite was always difficult and culture in special media gave the best results for diagnosis. The species involved in transmission was Leishmania (Viannia) braziliensis. Vectors included phlebotomine sand flies (Diptera: Psychodidae) of the genus Lutzomyia, and the most common species was Lutzomyia intermedia, captured mainly on the external walls of houses. CONCLUSIONS: ATL in Rio de Janeiro is mostly a cutaneous disease. In general, the cases showed great sensitivity to antimony. A pattern of peridomestic transmission seems to be the rule.     

Clinical and epidemiological aspects of American cutaneous leishmaniasis with genital involvement

Genital lesions are an unusual presentation of American cutaneous leishmaniasis. Conditions such as disseminated cutaneous leishmaniasis and HIV infection may be associated with genital involvement. The authors present five cases of American cutaneous leishmaniasis with genital lesions and discuss the clinical and epidemiological aspects observed in this case series.     

Facial and oral aspects of some venereal and tropical diseases

Diseases of the tropical areas include some venereal diseases, and they are still very prevalent in some countries; Brazil is one of them. Very few cases are originated in large cities, as Rio de Janeiro, but at the University Hospital of the Federal University of Rio de Janeiro we also see those patients who come from the interior of the State of Rio de Janeiro or from other states to seek medical care at better equipped hospitals for this type of investigation and therapy. Venereal and tropical dermatoses have many different cutaneous manifestations and may affect skin in several locations. The face is one of the affected areas especially when the disease has a predilection for cartilage, oral and/or nasal mucosa. Alterations observed on the skin of the face and on the mucosa of the mouth of some tropical diseases, such as leprosy, leishmaniasis, paracoccidioidomycosis, donovanosis, and syphilis, as they are observed in Brazil, are presented and discussed in this article.     

American tegumentary leishmaniasis: correlations among immunological, histopathological and clinical parameters

BACKGROUND

American tegumentary leishmaniasis has an annual incidence of 1 to 1.5 million cases. In some cases, the patient''s immune response can eliminate the parasite, and the lesion spontaneously resolves. However, when this does not occur, patients develop the disseminated form of the disease.

OBJECTIVE

To investigate the association between clinical, laboratory and pathological findings in cases of American tegumentary leishmaniasis.

METHODS

A retrospective study of the medical records of 47 patients with American cutaneous leishmaniasis. Clinical, laboratory and epidemiological data were collected, and semi-quantitative histopathological analyses were performed using the Spearman correlation coefficient (p <0.05).

RESULTS

Mean patient age was 40.5 years. A total of 29.7% individuals were female and 70.2% were male, and 40.4% of the patients were farmers. The ulcerative form was found in 53.2% of patients, of whom 59.6% had lesions in the limbs. The average time to diagnosis was 22.3 months. The following positive correlations were significant: age and duration of the disease, Montenegro reaction, degree of granulomatous transformation and epithelioid cell count; duration of disease, Montenegro reaction and number of lymphocytes; epithelial hyperplasia and edema, hemorrhaging, and epithelial aggression; number of plasmocytes and number of parasites. The main negative correlations found were as follows: age and serology; time and parasite load; epithelial hyperplasia and degree of granulomatous transformation.

CONCLUSION

The long duration of the disease could be explained by the fact that lesions were relatively asymptomatic, and therefore ignored by patients with low literacy levels. Individuals may have simply waited for spontaneous healing, which proved to be dependent on the activation of hypersensitivity mechanisms.     

History of leprosy in Rio de Janeiro

The record of the first cases of leprosy in Rio de Janeiro dates from the seventeenth century. The first local host of leprosy patients was created from 1741, and the first colonies hospitals were built in the early twentieth century, in order to avoid contagion of the population. The first structures dedicated to research also date from this time: the Leprosy International Institute, the Leprology Institute, and the Leprosy Laboratory of the Oswaldo Cruz Foundation, where the most prestigious leprologists of Rio de Janeiro worked. Currently, investigations are focused on the Oswaldo Cruz Foundation; additionally, leprosy patients are treated at municipal health centers and state hospitals, and former colony hospitals only accept patients with severe disabilities.     

Recurrent cutaneous leishmaniasis

We present a case of an 18-year-old male patient who, after two years of inappropriate treatment for cutaneous leishmaniasis, began to show nodules arising at the edges of the former healing scar. He was immune competent and denied any trauma. The diagnosis of recurrent cutaneous leishmaniasis was made following positive culture of aspirate samples. The patient was treated with N-methylglucamine associated with pentoxifylline for 30 days. Similar cases require special attention mainly because of the challenges imposed by treatment.     

Diagnostic methods to cutaneous leishmaniasis detection in domestic dogs and cats

Cutaneous leishmaniasis is caused by different species of Leishmania. In domestic animals such as dogs and cats, the diagnostic consists of clinical, epidemiological and serological tests, which changes among countries all around the world. Because of this diversity in the methods selected, we propose this systematic literature review to identify the methods of laboratory diagnosis used to detect cutaneous leishmaniasis in domestic dogs and cats in the Americas. Articles published in the last 5 years were searched in PubMed, ISI Web of Science, LILACS and Scielo, and we selected 10 papers about cutaneous leishmaniasis in dogs and cats in the Americas. In Brazil, often the indirect immunofluorescence and enzyme immunoassay (ELISA) have been applied. Other countries like United States and Mexico have been using antigenic fractions for antibodies detections by Western blot. ELISA and Western blot showed a higher sensitivity and efficacy in the detection of leishmaniasis. Analysis of sensibility and specificity of the methods was rarely used. Although confirmatory to leishmaniasis, direct methods for parasites detection and polymerase chain reaction showed low positivity in disease detection. We suggested that more than one method should be used for the detection of feline and canine leishmaniasis. Serological methods such as Western blot and enzyme immunoassay have a high efficacy in the diagnosis of this disease.     

Clinical features of cutaneous and disseminated cutaneous leishmaniasis caused by Leishmania (Viannia) braziliensis in Paraty, Rio de Janeiro

Background  American tegumentary leishmaniasis (ATL) caused by Leishmania (Viannia) braziliensis is endemic in Rio de Janeiro State (RJ), where the disease shows epidemiologic and clinical characteristics distinct from those of ATL in other Brazilian regions. Paraty is the second most important endemic area in RJ; however, reports on leishmaniasis in this region refer to the occurrence of the disease without describing its characteristics.
Methods  The clinical features of 71 cases of ATL reported between 1991 and 1997 in Paraty are presented. Thirty patients were re-evaluated 10 years later.
Results  Males and females were affected in similar proportions, and the disease was more prevalent in patients aged between 10 and 49 years (63.4%). Cutaneous leishmaniasis was the most prevalent clinical form observed. Unique lesions were present in 69% of cases, 91.6% of which displayed an ulcerated aspect. Although mucosal leishmaniasis was not observed, severe clinical manifestations, such as disseminated cutaneous lesions caused by L. braziliensis , were diagnosed in two patients. These patients presented skin lesions with different clinical aspects spread throughout the body, as well as low cellular immune responses. Montenegro skin test (92% positivity) and serology (8% IgM and 56% IgG anti- Leishmania positive results) were the most utilized tests for supporting the diagnosis of leishmaniasis. Parasites, detected in 27 of the 33 cases analyzed, were characterized as L. braziliensis .
Conclusion  ATL in Paraty shares the clinical and laboratory characteristics reported for ATL in other regions of RJ, probably because of the similar epidemiologic context related to the Atlantic rainforest region.     

Intralesional therapy of American cutaneous leishmaniasis with pentavalent antimony in Rio de Janeiro, Brazil – an area of Leishmania (V.) braziliensis transmission

Background The drug of choice for leishmaniasis is pentavalent antimony and different regimens are under continuous evaluation. The ideal therapy should be simple, effective, and with no or minor side-effects, in this paper we have studied the efficacy of intralesionally applied antimony in New World cutaneous leishmaniasis. Methods Seventy-four patients from Rio de Janeiro state, Brazil, and presenting with single ulcerative cutaneous lesions mainly located on the trunk or extremities were enrolled in the study. The drug employed was N-methyl glucamine (425 mg of Sb^v in each 5 ml ampoule). Each lesion was infiltrated with the drug at the four cardinal points in order to achieve complete blanching. Results Of the 74 patients, 59 (80%) were healed after a 12–week interval. Extensive follow-up (up to 10 years) disclosed no relapses or the development of mucosal lesions. Conclusions The aim of therapy in New World cutaneous leishmaniasis is the healing of the cutaneous lesion and the prevention of late mucosal damage. Both conditions were achieved with the treatment employed with no side-effects and a considerable decrease in costs. In addition, the method is easy to apply in the field.     

Identification of Leishmania species by high-resolution DNA dissociation in cases of American cutaneous leishmaniasis

BackgroundAmerican cutaneous leishmaniasis is an infectious dermatosis caused by protozoa of the genus Leishmania, which comprises a broad spectrum of clinical manifestations depending on the parasite species involved in the infections and the immunogenetic response of the host. The use of techniques for amplification of the parasites DNA based on polymerase chain reaction polymerase chain reaction and the recent application of combined techniques, such as high-resolution DNA dissociation, have been described as a viable alternative for the detection and identification of Leishmania spp. in biological samples.ObjectivesTo identify the Leishmania species using the polymerase chain reaction high-resolution DNA dissociation technique in skin biopsies of hospital-treated patients, and compare with results obtained by other molecular identification techniques.MethodsA retrospective study assessing patients with suspected American cutaneous leishmaniasis seen at a hospital in São Paulo/Brazil was conducted. The paraffin blocks of 22 patients were analyzed by polymerase chain reaction high-resolution DNA dissociation to confirm the diagnosis and identify the species.ResultsOf the 22 patients with suspected American cutaneous leishmaniasis, the parasite was identified in 14, comprising five cases (35.6%) of infection by L. amazonensis, four (28.5%) by L. braziliensis, two (14.4%) by L. amazonensis + L. infantum chagasi, two (14.4%) by L. guyanensis, and one (7.1%) by Leishmania infantum chagasi. In one of the samples, in which the presence of amastigotes was confirmed on histopathological examination, the polymerase chain reaction high-resolution DNA dissociation technique failed to detect the DNA of the parasite.Study limitationsThe retrospective nature of the study and small number of patients.ConclusionsThe method detected and identified Leishmania species in paraffin-embedded skin biopsies with a sensitivity of 96.4% and could be routinely used in the public health system.     

New World Cutaneous Leishmaniasis Treated with Intralesional Injection of Pentavalent Antimony

Cutaneous leishmaniasis is a skin infection caused by the Leishmania species, an intracellular protozoan parasite that is transmitted by various species of female sandflies. According to the geographic distribution and vectors, leishmaniasis is classified as Old World or New World cutaneous leishmaniasis. In Korea, 24 cases of Old World cutaneous leishmaniasis have been reported, but New World cutaneous leishmaniasis has not been reported as yet. A 37-year-old man presented with a 3-month history of a painful and erythematous nodule with two satellite papules on the left postauricular area and a papule on the left arm after traveling to the Amazon region in Brazil. After we performed skin biopsies of the lesions, diagnosis of cutaneous leishmaniasis was made by the histopathological findings. After intralesional injection of sodium stibogluconate (Pentostam®, GlaxoSmithKline) twice a week for 4 weeks, the lesions improved with scarring. Herein, we discuss this case of New World cutaneous leishmaniasis that was successfully treated with intralesional injection of sodium stibogluconate (Pentostam®) in Korea.     

Cutaneous New World Leishmaniasis on a Port-wine stain birthmark

We present an interesting case report of two sarcoid-like lesions on a port-wine stain (PWS) birthmark in a Brazilian patient which on investigation proved to be cutaneous leishmaniasis.     

South American cutaneous leishmaniasis: report of ten cases in Israeli travelers

Background Cutaneous South American leishmaniasis is caused by several species of leishmaniasis. Lack of appropriate treatment may lead to mucocutaneous leishmaniasis, mainly with L. b. braziliensis and L. b. panamensis.
Objective To describe the clinical findings of Israeli travelers infected with cutaneous South American leishmaniasis and to draw attention to this problem.
Subjects Ten patients were interviewed, examined and treated.
Results Twenty-two lesions of cutaneous leishmaniasis were found, all in exposed areas. Patients were seen by an average three physicians (range 1–6) before the final diagnosis was confirmed by direct smear, after an average period of 125 days (range 88–270 days). Treatment with Pentostam was started after an average period of 134 days (range 94–275 days). All lesions healed completely, but with scarring.
Conclusion Travelers to endemic areas, as well as physicians, should be instructed about the potential risks and the clinical manifestations of cutaneous and mucocutaneous South American leishmaniasis. Such awareness will prevent undue delay in diagnosis and treatment.     

Sporotrichosis with widespread cutaneous lesions: report of 24 cases related to transmission by domestic cats in Rio de Janeiro,Brazil

Background Sporotrichosis most commonly presents as a localized lymphocutaneous infection following traumatic inoculation of soil, vegetables or organic substrates contaminated with the dimorphic fungus Sporothrix schenckii. Cases of widespread cutaneous lesions are rare. There have been isolated reports of household outbreaks of sporotrichosis involving cats and humans. Methods We report 24 cases of culture‐proven sporotrichosis presenting with widespread cutaneous lesions. Results These 24 cases are part of an epidemic currently occurring in Rio de Janeiro. All patients reported contact with cats with sporotrichosis and 17 reported a history of a scratch or bite. Clinical manifestations included fixed lesions at multiple anatomical sites, and fixed lesions associated with the lymphocutaneous, bilateral lymphocutaneous and mucosal forms of the disease. Two patients were alcoholics and one patient was diabetic, while the remaining patients did not present any immunosuppressing condition. All patients responded to treatment with itraconazole. Conclusions The domestic cat has played an important role in the transmission of sporotrichosis in Rio de Janeiro and seems to have contributed to this unusual clinical manifestation.     

Exuberant case of verrucous cutaneous leishmaniasis

Cutaneous leishmaniasis represents a public health problem that affects 85 countries. It is an endemic disease in Brazil, having an important socioeconomic impact. An exuberant case of cutaneous leishmaniasis is reported herein. A 28-year-old male patient with Down syndrome had had verrucous plaques on the back for over a year, with progressive growth. PCR of a lesion sample was positive for Leishmania braziliensis. The patient's condition was classified as atypical cutaneous leishmaniasis. He was successfully treated with amphotericin B and miltefosine. The treatment remains a challenge, given the toxicity and low cure rate of the currently recommended drugs.     

Bed bug dermatitis,description of two cases in Rio de Janeiro, Brazil

Bed bugs are hematophagous insects which due to their morphological and biological characteristics are able to easily adapt themselves to human households. The authors describe two cases of dermatitis caused by bed bug bites in the city of Rio de Janeiro, Brazil. Patients presented linear lesions in the usual "breakfast, lunch and dinner" arrangement, suggesting this diagnosis. A visit to their dwellings showed infestation of insects identified as Cimex hemipterus. The knowledge of these insects by the dermatological community will contribute to an accurate diagnosis as well as subsidize the dissemination of information aiming for prevention.     

Clinical epidemiological profile of vitiligo in children and adolescents

94 children and 25 adolescents, 42% male and 58% female, aged predominantly between six and ten years old (40%) were studied at the Martagão Gesteira Childcare and Pediatrics Institute (Rio de Janeiro Federal University) between 2005 and 2011. The prevalent clinical form of vitiligo was the generalized type (34%). Although the clinical response was similar between the treatment modalities, we decided for low and high power topical steroids in our routine. Halo nevi were found in seven (5.9%) cases. Thirty (25%) patients underwent specialized evaluation and 18 (60%) reported some relevant psychological situation.     

Cellular infiltrate in cutaneous leishmaniasis lesions and therapeutic outcome

BackgroundThe treatment of cutaneous leishmaniasis is a challenge. A better understanding of the in situ mechanisms involved in the evolution and cure of the disease is essential for the development of new therapies.ObjectiveCorrelate histopathological and immunological characteristics of cutaneous leishmaniasis lesions with clinical outcome after different treatment regimens.MethodsThe authors analyzed cellular infiltration and immunohistochemistry staining for CD4, CD8 and IL-17 in biopsy samples from 33 patients with cutaneous leishmaniasis before treatment. All patients were recruited in a randomized clinical trial at Corte de Pedra (Bahia-Brazil) and assigned to receive Glucantime®, Glucantime® + Oral Tamoxifen or Glucantime® + Topical Tamoxifen. Patients were followed for 2 to 6 months to define disease outcome.ResultsA similar expression of CD4, CD8 and IL-17 was observed in lesion samples regardless of clinical outcome. In general, a higher amount of CD8 cells were observed compared with CD4 cells. An important observation was that all patients whose cellular infiltrate did not contain plasma cells were cured after treatment.Study limitationsIsolated quantification of TCD8 and IL-17 using immunohistochemistry is insufficient to analyze the role of these molecules in the immunopathogenesis of cutaneous leishmaniasis. In addition, the expansion of the immunohistochemistry panel would allow a more complete analysis of the immune response in situ.ConclusionsThe absence of plasma cells in cutaneous leishmaniasis lesions was related to a favorable therapeutic outcome.