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Arora A, Mohta A. An unusual pediatric case of post kala azar dermal leishmaniasis: A hidden parasite under the veil of white. Clin Microbiol Infect 2023:S1198-743X(23)00118-0. [PMID: 36918142 DOI: 10.1016/j.cmi.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/21/2023] [Accepted: 03/05/2023] [Indexed: 03/14/2023]
Affiliation(s)
- Aakanksha Arora
- Department of Dermatology, Venereology and Leprology, Sardar Patel Medical College, Bikaner, Rajasthan, India
| | - Alpana Mohta
- Department of Dermatology, Venereology and Leprology, Sardar Patel Medical College, Bikaner, Rajasthan, India.
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Ghosh P, Roy P, Chaudhuri SJ, Das NK. Epidemiology of Post-Kala-azar Dermal Leishmaniasis. Indian J Dermatol 2021; 66:12-23. [PMID: 33911289 PMCID: PMC8061485 DOI: 10.4103/ijd.ijd_651_20] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Post-kala-azar dermal leishmaniasis (PKDL) is a cutaneous sequel of visceral leishmaniasis (VL) or kala-azar and has become an entity of epidemiological significance by virtue of its ability to maintain the disease in circulation during inter-epidemic periods. PKDL has been identified as one of the epidemiological marker of “kala-azar elimination programme.” Data obtained in 2018 showed PKDL distribution primarily concentrated in 6 countries, which includes India, Sudan, south Sudan, Bangladesh, Ethiopia, and Nepal in decreasing order of case-burden. In India, PKDL cases are mainly found in 54 districts, of which 33 are in Bihar, 11 in West Bengal, 4 in Jharkhand, and 6 in Uttar Pradesh. In West Bengal the districts reporting cases of PKDL cases include Darjeeling, Uttar Dinajpur, Dakshin Dinajpur, Malda, and Murshidabad. The vulnerability on the young age is documented in various studies. The studies also highlights a male predominance of the disease but recent active surveillance suggested that macular form of PKDL shows female-predominance. It is recommended that along with passive case detection, active survey helps in early identification of cases, thus reducing disease transmission in the community. The Accelerated plan for Kala-azar elimination in 2017 introduced by Government of India with the goal to eliminate Kala-azar as a public health problem, targets to reduceing annual incidence <1/10,000. Leishmania donovani is the established causative agent, but others like L. tropica or L. infantum may occasionally lead to the disease, especially with HIV-co-infection. Dermal tropism of the parasite has been attributed to overexpression of parasite surface receptors (like gp 63, gp46). Various host factors are also identified to contribute to the development of the disease, including high pretreatment IL 10 and parasite level, inadequate dose and duration of treatment, malnutrition, immuno-suppression, decreased interferon-gamma receptor 1 gene, etc. PKDL is mostly concentrated in the plains below an altitude of 600 mts which is attributed to the environment conducive for the vector sand fly (Phlebotumus). Risk factors are also linked to the habitat of the sand fly. Keeping these things in mind “Integrated vector control” is adopted under National vector borne disease control programme as one of the strategies to bring down the disease burden.
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Affiliation(s)
- Pramit Ghosh
- Department of Community Medicine, Purulia Government Medical College, Purulia, West Bengal, India
| | - Pritam Roy
- Departments of Community Medicine, Independent Researcher and Public Health Expert, Kolkata, West Bengal, India
| | - Surya Jyati Chaudhuri
- Departments of Microbiology, Purulia Government Medical College, Purulia, West Bengal, India
| | - Nilay Kanti Das
- Department of Dermatology, Bankura Sammilani Medical College, Bankura, West Bengal, India
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Zijlstra EE, Kumar A, Sharma A, Rijal S, Mondal D, Routray S. Report of the Fifth Post-Kala-Azar Dermal Leishmaniasis Consortium Meeting, Colombo, Sri Lanka, 14-16 May 2018. Parasit Vectors 2020; 13:159. [PMID: 32228668 PMCID: PMC7106569 DOI: 10.1186/s13071-020-04011-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 03/09/2020] [Indexed: 12/20/2022] Open
Abstract
The 5th Post-Kala-Azar Dermal Leishmaniasis (PKDL) Consortium meeting brought together PKDL experts from all endemic areas to review and discuss existing and new data on PKDL. This report summarizes the presentations and discussions and provides the overall conclusions and recommendations.
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Affiliation(s)
- Eduard E Zijlstra
- Drugs for Neglected Diseases Initiative, 15 Chemin Louis Dunant, 1202, Geneva, Switzerland.
| | - Amresh Kumar
- PATH, 15th Floor, Dr. Gopaldas Building, 28 Barakhamba Road, Connaught Place, New Delhi, 110001, India
| | - Abhijit Sharma
- PATH, 15th Floor, Dr. Gopaldas Building, 28 Barakhamba Road, Connaught Place, New Delhi, 110001, India
| | - Suman Rijal
- Drugs for Neglected Diseases Initiative, PHD House, 3rd Floor, 4/2 Siri Institutional Area, New Delhi, 110016, India
| | - Dinesh Mondal
- Nutrition and Clinical Services Division, International Center For Diarrheal Disease Research, Bangladesh (icddr,b), 63 Shaheed Taj Uddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Satyabrata Routray
- PATH, 15th Floor, Dr. Gopaldas Building, 28 Barakhamba Road, Connaught Place, New Delhi, 110001, India
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Hasnain G, Shomik MS, Ghosh P, Rashid MO, Hossain S, Hamano S, Mondal D. Post-Kala-Azar Dermal Leishmaniasis Without Previous History of Visceral Leishmaniasis. Am J Trop Med Hyg 2016; 95:1383-1385. [PMID: 27672208 DOI: 10.4269/ajtmh.16-0230] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 08/28/2016] [Indexed: 11/07/2022] Open
Abstract
Post-kala-azar dermal leishmaniasis (PKDL) without previous visceral leishmaniasis (VL) is a rare dermatological manifestation of Leishmania infection. To date, most of the reported cases neither showed parasitological confirmation nor explained the outcome of treatment. Herein, we report three confirmed cases that were were successfully cured after miltefosine treatment.
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Affiliation(s)
- Golam Hasnain
- Centre for Clinical Epidemiology and Biostatistics (CCEB), School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle (UoN), New South Wales, Australia.,Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammad Sohel Shomik
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Prakash Ghosh
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mamun Or Rashid
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shakhawat Hossain
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shinjiro Hamano
- Department of Parasitology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - Dinesh Mondal
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
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Desjeux P, Ghosh RS, Dhalaria P, Strub-Wourgaft N, Zijlstra EE. Report of the Post Kala-azar Dermal Leishmaniasis (PKDL) Consortium Meeting, New Delhi, India, 27-29 June 2012. Parasit Vectors 2013; 6:196. [PMID: 23819611 PMCID: PMC3733610 DOI: 10.1186/1756-3305-6-196] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 05/17/2013] [Indexed: 12/05/2022] Open
Abstract
Post kala-azar dermal leishmaniasis (PKDL) is a neglected complication of visceral leishmaniasis (VL)―a deadly, infectious disease that claims approximately 20,000 to 40,000 lives every year. PKDL is thought to be a reservoir for transmission of VL, thus, adequate control of PKDL plays a key role in the ongoing effort to eliminate VL. Over the past few years, several expert meetings have recommended that a greater focus on PKDL was needed, especially in South Asia. This report summarizes the Post Kala-Azar Dermal Leishmaniasis Consortium Meeting held in New Delhi, India, 27–29 June 2012. The PKDL Consortium is committed to promote and facilitate activities that lead to better understanding of all aspects of PKDL that are needed for improved clinical management and to achieve control of PKDL and VL. Fifty clinicians, scientists, policy makers, and advocates came together to discuss issues relating to PKDL epidemiology, diagnosis, pathogenesis, clinical presentation, treatment, and control. Colleagues who were unable to attend participated during drafting of the consortium meeting report.
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Affiliation(s)
- Philippe Desjeux
- PATH OWH, A-9, Qutub Institutional area, USO Road, New Delhi, India
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El Hassan AM, Khalil EAG, Elamin WM, El Hassan LAM, Ahmed ME, Musa AM. Misdiagnosis and mistreatment of post-kala-azar dermal leishmaniasis. Case Rep Med 2013; 2013:351579. [PMID: 23533426 PMCID: PMC3600135 DOI: 10.1155/2013/351579] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 01/21/2013] [Indexed: 11/17/2022] Open
Abstract
Post-kala-azar dermal leishmaniasis (PKDL) is a known complication of visceral leishmaniasis (VL) caused by L. donovani. It is rare in VL caused by L. infantum and L. chagasi. In Sudan, it occurs with a frequency of 58% among successfully treated VL patients. In the majority of cases, PKDL can be diagnosed on the basis of clinical appearance, distribution of the lesions, and past history of treated VL. The ideal diagnostic method is to demonstrate the parasite in smears, by culture or PCR. Diagnosis is particularly difficult in patients who develop PKDL in the absence of previous history of visceral leishmaniasis. We describe a case of cutaneous leishmaniasis misdiagnosed as PKDL and 3 cases of PKDL who were either misdiagnosed or mistreated as other dermatoses. This caused exacerbation of their disease leading to high parasite loads in the lesions and dissemination to internal organs in one of the patients, who was also diabetic. The latter patient had L. major infection. A fourth patient with papulonodular lesions on the face and arms of 17-year duration and who was misdiagnosed as having PKDL is also described. He turned out to have cutaneous leishmaniasis due to L. major. Fortunately, he was not treated with steroids. He was cured with intravenous sodium stibogluconate.
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Affiliation(s)
- Ahmed Mohamed El Hassan
- Leishmaniasis Research Group, Institute of Endemic Diseases, University of Khartoum, Medical Campus, Qasr Avenue, P.O. Box 102, 11111 Khartoum, Sudan
| | - Eltahir Awad Gasim Khalil
- Leishmaniasis Research Group, Institute of Endemic Diseases, University of Khartoum, Medical Campus, Qasr Avenue, P.O. Box 102, 11111 Khartoum, Sudan
- Department of Clinical Pathology and Immunology, Institute of Endemic Diseases, University of Khartoum, P.O. Box 45235, 11111 Khartoum, Sudan
| | - Waleed Mohamed Elamin
- Leishmaniasis Research Group, Institute of Endemic Diseases, University of Khartoum, Medical Campus, Qasr Avenue, P.O. Box 102, 11111 Khartoum, Sudan
| | - Lamyaa Ahmed Mohamed El Hassan
- Leishmaniasis Research Group, Institute of Endemic Diseases, University of Khartoum, Medical Campus, Qasr Avenue, P.O. Box 102, 11111 Khartoum, Sudan
| | - Mogtaba Elsaman Ahmed
- Leishmaniasis Research Group, Institute of Endemic Diseases, University of Khartoum, Medical Campus, Qasr Avenue, P.O. Box 102, 11111 Khartoum, Sudan
| | - Ahmed Mudawi Musa
- Leishmaniasis Research Group, Institute of Endemic Diseases, University of Khartoum, Medical Campus, Qasr Avenue, P.O. Box 102, 11111 Khartoum, Sudan
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Ozaki M, Islam S, Rahman KM, Rahman A, Luby SP, Bern C. Economic consequences of post-kala-azar dermal leishmaniasis in a rural Bangladeshi community. Am J Trop Med Hyg 2011; 85:528-34. [PMID: 21896817 DOI: 10.4269/ajtmh.2011.10-0683] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Post-kala-azar dermal leishmaniasis (PKDL) is a complication of visceral leishmaniasis. Bangladesh national treatment guidelines during the study period called for 120 intramuscular injections of sodium antimony gluconate (SAG). We assessed care-seeking behavior, diagnosis and treatment costs, and coping strategies among 134 PKDL patients; 56 (42%) patients had been treated with SAG, and 78 (58%) remained untreated. The median direct cost per patient treated was US$367 (interquartile range [IQR] = 90-284), more than two times the estimated per capita annual income for the study population. The most common coping strategy was to take a loan; the median amount borrowed was US$98 (IQR = 71-150), with a median interest of US$32 (IQR = 16-95). Households lost a median of 123 work-days per patient treated. The current regimen for PKDL imposes a significant financial burden, reinforcing the link between poverty and visceral leishmaniasis. More practical shorter-course regimens for PKDL are urgently needed to achieve national and regional visceral leishmaniasis elimination goals.
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Affiliation(s)
- Masayo Ozaki
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Saha S, Mazumdar T, Anam K, Ravindran R, Bairagi B, Saha B, Goswami R, Pramanik N, Guha SK, Kar S, Banerjee D, Ali N. Leishmania promastigote membrane antigen-based enzyme-linked immunosorbent assay and immunoblotting for differential diagnosis of Indian post-kala-azar dermal leishmaniasis. J Clin Microbiol 2005; 43:1269-77. [PMID: 15750095 PMCID: PMC1081224 DOI: 10.1128/jcm.43.3.1269-1277.2005] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Diagnosis of post-kala-azar dermal leishmaniasis (PKDL), caused by Leishmania donovani, is difficult, as the dermal lesions are of several types and resemble those caused by other skin diseases, especially leprosy. Since the disease generally appears very late after the clinical cure of kala-azar in India, it is also difficult to correlate PKDL with a previous exposure to L. donovani. Very few attempts have been made so far to diagnose PKDL serologically, and the diagnostic methods vary in their sensitivities and specificities. Diagnosis of PKDL through sophisticated PCR methods, although highly sensitive, has limited practical use. We have developed a serodiagnostic method using an enzyme-linked immunosorbent assay to detect specific immunoglobulin (Ig) isotypes and IgG subclass antibodies in the sera of Indian PKDL patients. Our assay, which uses L. donovani promastigote membrane antigens, was 100% sensitive for the detection of IgG and 96.7% specific for the detection of IgG and IgG1. Optical density values for individual patients, however, demonstrated wide variations. Western blot analysis based on IgG reactivity could differentiate patients with PKDL from control subjects, which included patients with leprosy, patients from areas where kala-azar is endemic, and healthy subjects, by the detection of polypeptides of 67, 72, and 120 kDa. The recognition patterns of the majority of serum samples from patients with PKDL were also distinct from those of the serum samples from patients with visceral leishmaniasis (VL), at least for a 31-kDa polypeptide. To further differentiate patients with PKDL from those with active and cured VL, we analyzed the specific titers of the Ig isotypes and IgG subclasses. High levels of IgG, IgG1, IgG2, and IgG3 antibodies significantly differentiated patients with PKDL from patients cured of VL. The absence of antileishmanial IgE and IgG4 in patients with PKDL differentiated these patients from those with active VL. These results imply intrinsic differences in the antibodies generated in the sera from patients with PKDL and VL.
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Affiliation(s)
- Samiran Saha
- Indian Institute of Chemical Biology, 4, Raja. S. C. Mullick Rd., Calcutta 700032, India
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Zijlstra EE, Musa AM, Khalil EAG, el-Hassan IM, el-Hassan AM. Post-kala-azar dermal leishmaniasis. THE LANCET. INFECTIOUS DISEASES 2003; 3:87-98. [PMID: 12560194 DOI: 10.1016/s1473-3099(03)00517-6] [Citation(s) in RCA: 353] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Post-kala-azar dermal leishmaniasis (PKDL) is a complication of visceral leishmaniasis (VL); it is characterised by a macular, maculopapular, and nodular rash in a patient who has recovered from VL and who is otherwise well. The rash usually starts around the mouth from where it spreads to other parts of the body depending on severity. It is mainly seen in Sudan and India where it follows treated VL in 50% and 5-10% of cases, respectively. Thus, it is largely restricted to areas where Leishmania donovani is the causative parasite. The interval at which PKDL follows VL is 0-6 months in Sudan and 2-3 years in India. PKDL probably has an important role in interepidemic periods of VL, acting as a reservoir for parasites. There is increasing evidence that the pathogenesis is largely immunologically mediated; high concentrations of interleukin 10 in the peripheral blood of VL patients predict the development of PKDL. During VL, interferon gamma is not produced by peripheral blood mononuclear cells (PBMC). After treatment of VL, PBMC start producing interferon gamma, which coincides with the appearance of PKDL lesions due to interferon-gamma-producing cells causing skin inflammation as a reaction to persisting parasites in the skin. Diagnosis is mainly clinical, but parasites can be seen by microscopy in smears with limited sensitivity. PCR and monoclonal antibodies may detect parasites in more than 80% of cases. Serological tests and the leishmanin skin test are of limited value. Treatment is always needed in Indian PKDL; in Sudan most cases will self cure but severe and chronic cases are treated. Sodium stibogluconate is given at 20 mg/kg for 2 months in Sudan and for 4 months in India. Liposomal amphotericine B seems effective; newer compounds such as miltefosine that can be administered orally or topically are of major potential interest. Although research has brought many new insights in pathogenesis and management of PKDL, several issues in particular in relation to control remain unsolved and deserve urgent attention.
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Affiliation(s)
- E E Zijlstra
- EEZ is at the Department of Medicine, College of Medicine, Malawi
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El Hassan AM, Khalil EA. Post-kala-azar dermal leishmaniasis: does it play a role in the transmission of Leishmania donovani in the Sudan? Trop Med Int Health 2001; 6:743-4. [PMID: 11555443 DOI: 10.1046/j.1365-3156.2001.00776.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In 1997 a sudden outbreak of visceral leishmaniasis (VL) occurred in eastern Sudan, coinciding with an increase of post-kala-azar dermal leishmaniasis (PKDL) cases which may in part be because of sylvatic and anthroponotic transmission. Paradoxically, the more VL patients are treated, the higher the frequency of PKDL. If PKDL plays a role in transmission, its treatment would be expected to reduce infection in the area. Treatment of PKDL, however, requires four times the amount of Pentostam used for treating VL, and the drug is both expensive and in short supply.
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Affiliation(s)
- A M El Hassan
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan.
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Abstract
From the early 1900s, visceral leishmaniasis (VL; kala-azar) has been among the most important health problems in Sudan, particularly in the main endemic area in the eastern and central regions. Several major epidemics have occurred, the most recent--in Western Upper Nile province in southern Sudan, detected in 1988--claiming over 100,000 lives. The disease spread to other areas that were previously not known to be endemic for VL. A major upsurge in the number of cases was noted in the endemic area. These events triggered renewed interest in the disease. Epidemiological and entomological studies confirmed Phlebotomus orientalis as the vector in several parts of the country, typically associated with Acacia seyal and Balanites aegyptiaca vegetation. Infection rates with Leishmania were high, but subject to seasonal variation, as were the numbers of sand flies. Parasites isolated from humans and sand flies belonged to three zymodemes (MON-18, MON-30 and MON-82), which all belong to the L. donovani sensu lato cluster. Transmission dynamics have not been elucidated fully; heavy transmission in relatively scarcely populated areas such as Dinder national park suggested zoonotic transmission whereas the large numbers of patients with post kala-azar dermal leishmaniasis (PKDL) in heavily affected villages may indicate a human reservoir and anthroponotic transmission. Clinical presentation in adults and in children did not differ significantly, except that children were more anaemic. Fever, weight loss, hepato-splenomegaly and lymphadenopathy were the most common findings. PKDL was much more common than expected (56% of patients with VL developed PKDL), but other post-VL manifestations were also found affecting the eyes (uveitis, conjunctivitis, blepharitis), nasal and/or oral mucosa. Evaluation of diagnostic methods showed that parasitological diagnosis should still be the mainstay in diagnosis, with sensitivities for lymph node, bone marrow and spleen aspirates of 58%, 70% and 96%, respectively. Simple, cheap serological tests are needed. The direct agglutination test (DAT) had a sensitivity of 72%, specificity of 94%, positive predictive value of 78% and negative predictive value of 92%. As with other serological tests, the DAT cannot distinguish between active disease, subclinical infection or past infection. The introduction of freeze-dried antigen and control sera greatly improved the practicality and accuracy of the DAT in the field. An enzyme-linked immunosorbent assay using recombinant K39 antigen had higher sensitivity than DAT (93%). The polymerase chain reaction using peripheral blood gave a sensitivity of 70-93% and was more sensitive than microscopy of lymph node or bone marrow aspirates in patients with suspected VL. The leishmanin skin test (LST) was typically negative during active VL and converted to positive in c. 80% of patients 6 months after treatment. Immunological studies showed that both Th1 and Th2 cell responses could be demonstrated in lymph nodes from VL patients as evidenced by the presence of messenger ribonucleic acid for interleukin (IL)-10, interferon gamma and IL-2. Treatment of peripheral blood mononuclear cells from VL patients with IL-12 was found to drive the immune response toward a Th1 type response with the production of interferon gamma, indicating a potential therapeutic role for IL-12. VL responded well to treatment with sodium stibogluconate, which is still the first line drug at a dose of 20 mg/kg intravenously or intramuscularly per day for 15-30 d. Side effects and resistance were rare. Liposomal amphotericin B was effective, with few side effects. Control measures have not been implemented. Based on observations that VL does not occur in individuals who have a positive LST, probably because of previous cutaneous leishmaniasis, a vaccine containing heat-killed L. major promastigotes is currently undergoing a phase III trial.
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Affiliation(s)
- E E Zijlstra
- Department of Epidemiology and Clinical Sciences, Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan.
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Abstract
Post kala-azar dermal leishmaniasis (PKDL) is increasingly recognized in Sudan as a complication of visceral leishmaniasis (VL), occurring in c. 55% of patients after, or during treatment of, VL. The development of PKDL seems to be restricted to parasites of the Leishmania donovani sensu stricto cluster; no particular zymodeme has been found to be associated with it. In contrast to PKDL in India, PKDL in Sudan occurs within 0-6 months after treatment for VL. The rash may be macular, maculo-papular or nodular, and spreads from the perioral area to other parts of the body, depending on grade of severity. Young children are particularly at risk of developing more severe disease. In 16% of PKDL patients, parasites can be demonstrated by microscopy in lymph node or bone marrow aspirates and, with the aid of the polymerase chain reaction (PCR), in lymph nodes of 81% of patients, possibly indicating persistent visceralized infection. Diagnosis can be made by demonstration of parasites in skin smears or biopsies in 20-30% of cases; newer techniques, using PCR with skin smears, have higher sensitivity (83%). Monoclonal antibodies against L. donovani can detect parasites in 88% of biopsies. Serological tests are of limited value. The leishmanin skin test is positive in 50-60% of cases; there is an inverse relationship between the skin test result and severity of PKDL. In differential diagnosis, miliaria rubra is the most common problem; differentiation from leprosy is the most difficult. In biopsies, hyperkeratosis, parakeratosis, acanthosis, follicular plugging and liquefaction degeneration of the basal layer may be found in the epidermis; in the dermis there are varying intensities of inflammation with scanty parasites and mainly lymphocytes; macrophages and epithelioid cells may also be found. In 20% of cases discrete granulomas may be found. After VL, the immune response shifts from a Th2-type to a mixed Th1/Th2-type. High levels of interleukin-10 in skin biopsies as well as in peripheral blood mononuclear cells and plasma in patients with VL predict the development of PKDL. Treatment is needed only for those who have severe and prolonged disease; sodium stibogluconate (20 mg/kg/d for 2 months) is usually sufficient. (Liposomal) amphotericin B is effective, whereas ketoconazole, terbinafine and itraconazole are not.
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Affiliation(s)
- E E Zijlstra
- Department of Epidemiology and Clinical Sciences, Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
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Osman OF, Kager PA, Oskam L. Leishmaniasis in the Sudan: a literature review with emphasis on clinical aspects. Trop Med Int Health 2000; 5:553-62. [PMID: 10995097 DOI: 10.1046/j.1365-3156.2000.00598.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The literature on the leishmaniases in the Sudan is reviewed with an emphasis on clinical aspects and on literature related to the recent outbreaks in the south and east of the country. The numbers of cases of subclinical infection and post-kala azar dermal leishmaniasis in the recent outbreaks are remarkable. New diagnostic techniques have been introduced and evaluated, notably the direct agglutination test and polymerase chain reaction technology. The latter gives very promising results and further research into application of the technique is warranted. Treatment with pentavalent antimony is still satisfactory. The reservoir host has not been identified definitely.
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Affiliation(s)
- O F Osman
- Department of Zoology, Faculty of Science, University of Khartoum, Sudan
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Ismail A, Kharazmi A, Permin H, el Hassan AM. Detection and characterization of Leishmania in tissues of patients with post kala-azar dermal leishmaniasis using a specific monoclonal antibody. Trans R Soc Trop Med Hyg 1997; 91:283-5. [PMID: 9231195 DOI: 10.1016/s0035-9203(97)90075-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Sections from skin lesions and draining lymph nodes of patients with post kala-azar dermal leishmaniasis were examined using an immunoperoxidase method and a monoclonal antibody directed against Leishmania donovani. Parasites were detected in 22 of 25 biopsies (88%). In parallel sections stained by haematoxylin and eosin, parasites were detected in only 5 of 25 of the biopsies (20%). The demonstration of whole parasites or parasite antigen is diagnostic.
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Affiliation(s)
- A Ismail
- Centre of Medical Parasitology, University of Copenhagen, Denmark
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16
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Fahal AH, el Hag IA, el Hassan AM, Hashim FA. Leishmanial cholecystitis and colitis in a patient with visceral leishmaniasis. Trans R Soc Trop Med Hyg 1995; 89:284. [PMID: 7660434 DOI: 10.1016/0035-9203(95)90541-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- A H Fahal
- Department of Surgery, Faculty of Medicine, University of Khartoum, Sudan
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17
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Abstract
Leishmaniasis is a spectrum of diseases ranging in severity from cutaneous (CL), post-kala-azar dermal (PKDL), and diffuse cutaneous (DCL) to mucocutaneous (MCL) and visceral (VL) infections that are endemic in 86 tropical and subtropical countries around the world, accounting for 75,000 deaths per year. Different forms of leishmaniases are generally caused by different distinct species of Leishmania having a digenetic life cycle alternating between an aflagellated amastigote form replicative within the macrophages of the host and a flagellated promastigote form that multiplies within the gut of the sandfly. VL, MCL, PKDL, DCL, and CL forms of the disease can be arranged on a priority basis in accordance with the humoral immune responses of host. Generally, the cell-mediated immunity, particularly the delayed-type hypersensitivity to leishmanial antigens, is associated with CL, MCL, PKDL, and cured VL cases. The serodiagnosis of leishmaniasis appears to be an alternative to parasite detection in biopsy samples either by the staining of amastigotes or by culturing the amastigotes, which transform to a promastigote form and replicate. A battery of immunological procedures have been developed or adapted to demonstrate either humoral or cell-mediated immune responses against Leishmania for diagnosis and epidemiological survey. The sensitivity and specificity of such diagnostic methods depend on the type, source, and purity of antigen employed, as some of the leishmanial antigens have common cross-reactive epitopes shared with other microorganisms, particularly Trypanosoma, Mycobacteria, Plasmodia, and Schistosoma. Serodiagnostic techniques for the detection of antileishmanial antibodies have been employed with about 72 to 100, 23 to 90, 83, and 33 to 100% success in VL, CL, MCL, and PKDL patients, respectively. The Leishmanin skin test (LST) is useful to detect MCL and CL, with about 100 and 84% success, respectively. In PKDL, the gradual fall of antileishmanial antibody titer to some extent and the rise of delayed hypersensitivity to the parasite antigen are the characteristic features associated with the chronicity of the disease. The use of whole promastigote as the source of antigens in the direct agglutination test (DAT) and immunofluorescent test (IFAT) gave cross-reactions with the sera of leprosy, tuberculosis, and African trypanosomiasis patients. Again, the use of cell-free extracts of promastigotes generally gave false positive results with the sera of normal human and Chagas' disease, leprosy, tuberculosis, and malaria patients in enzyme-linked immunosorbent assay (ELISA), dot ELISA, immunodiffusion, immunoelectrophoresis, and counter-current immunoelectrophoresis tests.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- K Kar
- Leishmania Group, Indian Institute of Chemical Biology, Calcutta
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18
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Chang CC, Yu MW, Lu CF, Yang CS, Chen CJ. A nested case-control study on association between hepatitis C virus antibodies and primary liver cancer in a cohort of 9,775 men in Taiwan. J Med Virol 1994; 43:276-80. [PMID: 7523582 DOI: 10.1002/jmv.1890430315] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Most studies on the association between antibodies against hepatitis C virus (anti-HCV) and primary liver cancer (PLC) were limited to case-series, or cross-sectional case-control studies leaving a controversy on causal temporality. A nested case-control study on 38 newly-developed PLC patients and 152 matched controls selected from a cohort of 9,775 men in Taiwan recruited from September, 1984, to February, 1986, was carried out to examine the relation between HCV infection and PLC. Case-control pairs were matched on age (+/- 1 year), residence, and the date at recruitment. Serum samples collected from study subjects at the initial recruitment were examined for anti-HCV by enzyme immunoassay and hepatitis B surface antigen (HBsAg) by reverse passive hemagglutination assay combined with radioimmunoassay. History of cigarette smoking, alcohol consumption, vegetable consumption, vegetarian habit, and chronic liver diseases were also obtained through standardized interviews according to a structured questionnaire at the recruitment. After adjusting for HBsAg status and other risk factors, the anti-HCV was significantly associated with the development of PLC showing a multivariate-adjusted relative risk of 88.24. The results suggest that HCV infection may play an important role in the etiology of human PLC in Taiwan.
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Affiliation(s)
- C C Chang
- Institute of Public Health, National Taiwan University College of Public Health, Taipei
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19
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el-Hassan AM, Zijlstra EE, Meredith SE, Ghalib HW, Ismail A. Identification of Leishmania donovani using a polymerase chain reaction in patient and animal material obtained from an area of endemic kala-azar in the Sudan. Acta Trop 1993; 55:87-90. [PMID: 7903141 DOI: 10.1016/0001-706x(93)90051-c] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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20
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el Hassan AM, Ghalib HW, Zijlstra EE, Eltoum IA, Satti M, Ali MS, Ali HM. Post kala-azar dermal leishmaniasis in the Sudan: clinical features, pathology and treatment. Trans R Soc Trop Med Hyg 1992; 86:245-8. [PMID: 1329273 DOI: 10.1016/0035-9203(92)90294-m] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The clinical features, pathology, immune responses, diagnosis and treatment of post kala-azar dermal leishmaniasis (PKDL) in the Sudan are described and discussed. The disease is characterized by maculopapular or nodular lesions on the face, limbs or trunk. Lesions appear during or within months after the treatment of visceral leishmaniasis, but in 2 of 19 patients there was no previous history of kala-azar. PKDL may be confused with leprosy both clinically and pathologically. Similarities and differences between the 2 diseases are discussed. Unlike visceral leishmaniasis, the peripheral lymphoid cells of patients with PKDL respond to Leishmania antigen and some are leishmanin positive. The response to intravenous sodium stibogluconate (20 mg/kg for 30 d) was reasonably good but some patients required repeated or more prolonged treatment. Ketoconazole in a dose of 10 mg/kg daily for 4 weeks had no effect on PKDL.
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Affiliation(s)
- A M el Hassan
- Leishmaniasis Research Group, Medical Research Council, Khartoum, Sudan
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21
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Ghalib HW, Eltoum EA, Kroon CC, el Hassan AM. Identification of Leishmania from mucosal leishmaniasis by recombinant DNA probes. Trans R Soc Trop Med Hyg 1992; 86:158-60. [PMID: 1440775 DOI: 10.1016/0035-9203(92)90549-r] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Three cases of mucosal leishmaniasis are described. Parasites isolated from mucosal lesions were identified by Southern blot analysis of their genomic deoxyribonucleic acids (DNAs) using recombinant DNA probe pDK20. Parasites from 2 patients were identified as Leishmania donovani s.l. One of the patients had pure mucosal lesions, while in the second patient there was dissemination of the parasite to other organs. The spectrum of the disease caused by L. donovani is discussed. The parasite from the third patient was identified as L. major.
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Affiliation(s)
- H W Ghalib
- Department of Microbiology, College of Medicine, University of Fuba, Khartoum Centre, Sudan
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22
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Affiliation(s)
- G C Cook
- Department of Clinical Sciences, Hospital for Tropical Diseases, London, UK
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23
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Zijlstra EE, Ali MS, el-Hassan AM, el-Toum IA, Satti M, Ghalib HW, Sondorp E, Winkler A. Kala-azar in displaced people from southern Sudan: epidemiological, clinical and therapeutic findings. Trans R Soc Trop Med Hyg 1991; 85:365-9. [PMID: 1658990 DOI: 10.1016/0035-9203(91)90293-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Six hundred and ninety-three patients with kala-azar were seen in Khartoum, Sudan, from January 1989 to February 1990. They were almost exclusively from the Nuer tribe, originating from the western Upper Nile province in southern Sudan, an area not known previously to be endemic for kala-azar. Because of the civil war in southern Sudan no treatment was available locally and massive migration to northern Sudan occurred; many died on the way. All age groups were affected; there was a slight male preponderance (56%). In the clinical presentation, marked generalized lymphadenopathy was prominent (84%). Splenomegaly was absent in 4% of cases. Patients usually showed anaemia, leucopenia and/or thrombocytopenia. 623 patients were treated with sodium stibogluconate, 10 mg/kg for 30 d; relapse occurred in 4% and death in 12%. Latterly, 70 patients were treated with sodium stibogluconate at 2 x 10 mg/kg for 15 d, with relapse in 6% and death in 6%. The difference between the 2 regimens in the number of relapses and deaths was not significant. The outbreak may have been caused by a combination of factors: the introduction of the parasite from an endemic area to a non-immune population, the presence of malnutrition caused by loss of cattle and unavailability of other food sources, and possibly an ecological change in favour of the sandfly vector.
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Affiliation(s)
- E E Zijlstra
- Leishmaniasis Research Group, Medical Research Council, Sudan
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