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Joshi S, Dixit KK, Sharma V, Ramesh V, Singh R, Salotra P. Rapid Multiplex Loop-Mediated Isothermal Amplification (m-LAMP) Assay for Differential Diagnosis of Leprosy and Post-Kala-Azar Dermal Leishmaniasis. Am J Trop Med Hyg 2021; 104:2085-2090. [PMID: 33872215 PMCID: PMC8176499 DOI: 10.4269/ajtmh.19-0313] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 09/09/2019] [Indexed: 11/07/2022] Open
Abstract
Leprosy and post-kala-azar dermal leishmaniasis (PKDL) are co-endemic neglected tropical diseases often misdiagnosed because of close resemblance in their clinical manifestations. The test that aids in differential diagnosis of leprosy and PKDL would be useful in endemic areas. Here, we report development of a multiplex loop-mediated isothermal amplification (m-LAMP) assay for differential detection of Mycobacterium leprae and Leishmania donovani using a real-time fluorometer. The m-LAMP assay was rapid with a mean amplification time of 15 minutes, and analytical sensitivity of 1 fg for L. donovani and 100 fg for M. leprae. The distinct mean Tm values for M. leprae and L. donovani allowed differentiation of the two organisms in the m-LAMP assay. Diagnostic sensitivity of the assay was evaluated by using confirmed cases of leprosy (n = 40) and PKDL (n = 40) (tissue and slit aspirate samples). All the leprosy and PKDL samples used in this study were positive by organism-specific QPCR and loop-mediated isothermal amplification assays. The diagnostic sensitivity of the m-LAMP assay was 100% (95% CI: 91.2-100.0%) for detecting PKDL and 95% for leprosy (95% CI: 83.1-99.4%). Our m-LAMP assay was successfully used to detect both M. leprae and L. donovani in a patient coinfected with leprosy and macular PKDL. The m-LAMP assay is rapid, accurate, and applicable for differential diagnosis of leprosy versus PKDL, especially in endemic areas.
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Affiliation(s)
- Shweta Joshi
- Molecular Parasitology Laboratory, ICMR-National Institute of Pathology, Safdarjung Hospital Campus, New Delhi, India
| | - Keerti K. Dixit
- Molecular Parasitology Laboratory, ICMR-National Institute of Pathology, Safdarjung Hospital Campus, New Delhi, India
| | - Vanila Sharma
- Molecular Parasitology Laboratory, ICMR-National Institute of Pathology, Safdarjung Hospital Campus, New Delhi, India
| | - V. Ramesh
- Department of Dermatology, Safdarjung Hospital, New Delhi, India
| | - Ruchi Singh
- Molecular Parasitology Laboratory, ICMR-National Institute of Pathology, Safdarjung Hospital Campus, New Delhi, India
| | - Poonam Salotra
- Molecular Parasitology Laboratory, ICMR-National Institute of Pathology, Safdarjung Hospital Campus, New Delhi, India
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Abstract
The various lesions seen in the clinical presentation of post kala-azar dermal leishmaniasis (PKDL) are reflected in the histopathology of the type of lesion biopsied. The cells that form the dermal infiltrate include lymphocytes, histiocytes, and plasma cells in varying proportions. The infiltrate, which is mild and confined to the superficial dermis in macular lesion becomes denser with the increasing severity of the lesion. Leishman–Donovan bodies (LDB) in general are rarely demonstrable in macules and somewhat infrequently in the rest, though at times they may be numerous; mucosal lesions offer a greater chance of visualizing LDB than biopsies from the skin. A characteristic histomorphology in nodules is prominent follicular plugging with a dense plasma cell-rich lymphohistiocytic dermal infiltrate that shows an abrupt cut-off in the lower dermis, an appearance highly suggestive of PKDL even in the absence of LDB. Russell bodies within plasma cells, vascular changes, and xanthoma-like hue have been seen in plaques from chronic PKDL. The histopathologic picture in some may also mimic that seen in tuberculoid and lepromatous leprosy, and other granulomatous dermatoses. In contrast to Indian PKDL, epithelioid cell granulomas with giant cells are more common in African PKDL, and vascular changes are rare though neuritis showing LDB has been described.
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Affiliation(s)
- V Ramesh
- Department of Dermatology and STD, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India
| | - M Ramam
- Department of Dermatology, All India Institute of Medical Sciences, New Delhi, India
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Gedda MR, Singh B, Kumar D, Singh AK, Madhukar P, Upadhyay S, Singh OP, Sundar S. Post kala-azar dermal leishmaniasis: A threat to elimination program. PLoS Negl Trop Dis 2020; 14:e0008221. [PMID: 32614818 PMCID: PMC7332242 DOI: 10.1371/journal.pntd.0008221] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Leishmaniasis remains a public health concern around the world that primarily affects poor folks of the developing world spanning across 98 countries with mortality of 0.2 million to 0.4 million annually. Post kala-azar dermal leishmaniasis (PKDL) is the late skin manifestation of visceral leishmaniasis (VL). It has been reported that about 2.5% to 20% of patients recovered from VL develop PKDL having stilted macular or nodular lesions with parasites. In the Indian subcontinent (ISC), it manifests a few months after recovery from VL, though in Africa it can occur simultaneously with VL or a little later. New cases of PKDL are also observed without prior VL in the ISC. These individuals with PKDL represent an important but largely neglected reservoir of infection that perpetuates anthroponotic Leishmania donovani transmission in the ISC and can jeopardize the VL elimination program as these cases can infect the sand flies and spread the endemic. Therefore, it becomes imperative to eradicate PKDL as a part of the VL elimination program. With the limited treatment options besides little knowledge on PKDL, this review stands out in focusing on different aspects that should be dealt for sustained VL elimination.
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Affiliation(s)
- Mallikarjuna Rao Gedda
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
- Center for Cellular Engineering, NIH Clinical Center, Bethesda, Maryland, United States of America
| | - Bhawana Singh
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Dhiraj Kumar
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
- Department of Zoology, Rameshwar College, BRA Bihar University, Muzaffarpur, India
| | - Abhishek Kumar Singh
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Prasoon Madhukar
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Shreya Upadhyay
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Om Prakash Singh
- Department of Biochemistry, Institute of Science, Banaras Hindu University, Varanasi, India
| | - Shyam Sundar
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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Das A, Kumar P, Barkat R. Nodular post kala-azar dermal leishmaniasis: A report on two cases and brief review of literature. Indian Dermatol Online J 2020; 11:856-858. [PMID: 33235869 PMCID: PMC7678516 DOI: 10.4103/idoj.idoj_645_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 03/08/2020] [Accepted: 06/01/2020] [Indexed: 11/08/2022] Open
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Sundharkrishnan L, North JP. Histopathologic features of cutaneous leishmaniasis and use of CD1a staining for amastigotes in Old World and New World leishmaniasis. J Cutan Pathol 2017; 44:1005-1011. [PMID: 28892183 DOI: 10.1111/cup.13032] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 08/07/2017] [Accepted: 08/16/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Positive CD1a staining of Leishmania has been reported in Old World leishmaniasis, but the sensitivity of such staining for other Leishmania species is unknown. METHODS A retrospective review was done on skin biopsies of proven cutaneous leishmaniasis based on histology, immunohistochemistry, culture and/or polymerase chain reaction (PCR). We assessed the pattern of inflammation present and assessed for CD1a (MTB1 clone) positivity in amastigotes. Patients without a clearly documented travel history to delineate Old vs New World leishmaniasis and cases without tissue for CD1a staining were excluded. RESULTS Various patterns of granulomatous inflammation were observed including sarcoidal (31%), diffuse (25%), suppurative and granulomatous (25%), palisaded (13%) and lichenoid (6%). CD1a staining was positive in amastigotes in 9 of 16 cases (56%). Five of 7 (71%) cases of Old World disease were CD1a positive, while 4 of 9 cases (44%) of New World cases were positive. CONCLUSIONS Multiple patterns of granulomatous inflammation occur in cutaneous leishmaniasis. Our results confirm CD1a (MTB1 clone) can be a diagnostic adjunct to highlight amastigotes in biopsies of cutaneous leishmaniasis, with variable positivity in both Old World and New World forms of the disease. As 44% of cases were CD1a negative in our cohort, there are significant limitations to this screening approach.
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Affiliation(s)
| | - Jeffrey P North
- Department of Dermatology, University of California San Francisco, San Francisco, California.,Department of Pathology, University of California San Francisco, San Francisco, California
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Bandyopadhyay A, Majumdar K, Gangopadhyay M, Koley S. Fine-needle sampling provides appreciable diagnostic yield in lesions of post kala azar dermal leishmaniasis: analysis of four cases from North Eastern India. Diagn Cytopathol 2013; 42:525-9. [PMID: 23440979 DOI: 10.1002/dc.22953] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 10/02/2012] [Accepted: 01/01/2013] [Indexed: 11/10/2022]
Abstract
Post-kala-azar dermal leishmaniasis (PKDL) is a sequel of visceral leishmaniasis (VL), usually occurring 6 months to 3 years after VL. Spectrum of cutaneous lesions in PKDL can be hypopigmented macules, nodules, plaques, or erythema. It is usually diagnosed clinically, supplemented by ancillary techniques like skin smear examination, histopathology, polymerase chain reaction, and monoclonal antibody test. Literature on the role of cytology in the diagnosis of PKDL is extremely limited. Here we highlight the appreciable yield of fine-needle sampling in four cases of PKDL, which may be considered as a useful diagnostic aid.
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Srividya G, Kulshrestha A, Singh R, Salotra P. Diagnosis of visceral leishmaniasis: developments over the last decade. Parasitol Res 2011; 110:1065-78. [DOI: 10.1007/s00436-011-2680-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2011] [Accepted: 10/04/2011] [Indexed: 10/15/2022]
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Katara GK, Ansari NA, Verma S, Ramesh V, Salotra P. Foxp3 and IL-10 expression correlates with parasite burden in lesional tissues of post kala azar dermal leishmaniasis (PKDL) patients. PLoS Negl Trop Dis 2011; 5:e1171. [PMID: 21655313 PMCID: PMC3104974 DOI: 10.1371/journal.pntd.0001171] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Accepted: 03/22/2011] [Indexed: 12/13/2022] Open
Abstract
Background Post kala-azar dermal leishmaniasis (PKDL), a sequel to visceral leishamaniasis (VL) in 5–15% cases, constitutes a parasite reservoir important in disease transmission. The precise immunological cause of PKDL outcome remains obscure. However, overlapping counter regulatory responses with elevated IFN-γ and IL-10 are reported. Methodology/Principal Findings Present study deals with ex-vivo mRNA and protein analysis of natural regulatory T cells (nTreg) markers (Foxp3, CD25 and CTLA-4) and IL-10 levels in lesion tissues of PKDL patients at pre and post treatment stages. In addition, correlation of nTreg markers and IL-10 with parasite load in tissue lesions was investigated. mRNA levels of nTreg markers and IL-10 were found significantly elevated in pre-treatment PKDL cases compared to controls (Foxp3, P = 0.0009; CD25 & CTLA-4, P<0.0001; IL-10, P<0.0001), and were restored after treatment. Analysis of nTreg cell markers and IL-10 in different clinical manifestations of disease revealed elevated levels in nodular lesions compared to macules/papules. Further, Foxp3, CD25 and IL-10 mRNA levels directly correlated with parasite load in lesions tissues. Conclusion/Significance Data demonstrated accumulation of nTreg cells in infected tissue and a correlation of both IL-10 and nTreg levels with parasite burden suggesting their role in disease severity in PKDL. Post kala azar dermal leishamniasis (PKDL), an unusual dermatosis develops in 5–15% of apparently cured visceral leishmaniasis cases in India and in about 60% of cases in Sudan. PKDL cases assume importance since they constitute a major human reservoir for the parasite. Inadequate treatment of VL, genetics, nutrition and immunological mechanisms that allow renewed multiplication of latent parasites or reinfection predispose to PKDL. Immunopathogenesis of PKDL is poorly understood. IL-10 is widely accepted as an immuno-suppressive cytokine and produced by diverse cell populations including, B cells, macrophages and CD4+ T cells. Natural T regulatory (nTreg) cells are subpopulation of CD4+ T cells that inhibit the response of other T cells. In this study we reported the accumulation of nTreg cells in lesion tissues of PKDL patients. Further correlation of Treg markers and IL-10 with parasite load in lesion tissues suggested a role of IL-10 and Treg in parasite establishment or persistence. Further studies are warranted to explore antigen specific IL-10 source in lesion tissues and unravel the concerted induction or accumulation of Treg in PKDL.
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Affiliation(s)
| | | | - Sandeep Verma
- Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi, India
| | - V. Ramesh
- Department of Dermatology, Safdarjung Hospital, New Delhi, India
| | - Poonam Salotra
- Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi, India
- * E-mail:
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Ramesh V, Singh R, Salotra P. Short communication: Post-kala-azar dermal leishmaniasis - an appraisal. Trop Med Int Health 2007; 12:848-51. [PMID: 17596251 DOI: 10.1111/j.1365-3156.2007.01854.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This short descriptive paper assesses diagnostics, clinical characteristics and therapy of both Indian and African post-kala-azar dermal leishmaniasis.
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Affiliation(s)
- V Ramesh
- Department of Dermatology & Regional STD Centre, and Institute of Pathology (ICMR), Safdarjang Hospital and V.M. Medical College, New Delhi, India.
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Castro R, Scott K, Jordan T, Evans B, Craig J, Peters EL, Swier K. The ultrastructure of the parasitophorous vacuole formed by Leishmania major. J Parasitol 2007; 92:1162-70. [PMID: 17304790 DOI: 10.1645/ge-841r.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Protozoan parasites of Leishmania spp. invade macrophages as promastigotes and differentiate into replicative amastigotes within parasitophorous vacuoles. Infection of inbred strains of mice with Leishmania major is a well-studied model of the mammalian immune response to Leishmania species, but the ultrastructure and biochemical properties of the parasitophorous vacuole occupied by this parasite have been best characterized for other species of Leishmania. We examined the parasitophorous vacuole occupied by L. major in lymph nodes of infected mice and in bone marrow-derived macrophages infected in vitro. At all time points after infection, single L. major amastigotes were wrapped tightly by host membrane, suggesting that amastigotes segregate into separate vacuoles during replication. This small, individual vacuole contrasts sharply with the large, communal vacuoles occupied by Leishmania amazonensis. An extensive survey of the literature revealed that the single vacuoles occupied by L. major are characteristic of those formed by Old World species of Leishmania, while New World species of Leishmania form large vacuoles occupied by many amastigotes.
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Affiliation(s)
- Ramon Castro
- Department of Biological Sciences, Chicago State University, 9501 South King Drive, Chicago, Illinois 60628, USA
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Singh R, Subba Raju BV, Jain RK, Salotra P. Potential of direct agglutination test based on promastigote and amastigote antigens for serodiagnosis of post-kala-azar dermal leishmaniasis. CLINICAL AND DIAGNOSTIC LABORATORY IMMUNOLOGY 2005; 12:1191-4. [PMID: 16210482 PMCID: PMC1247836 DOI: 10.1128/cdli.12.10.1191-1194.2005] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Post-kala-azar dermal leishmaniasis (PKDL) is a dermal complication, a sequel to kala-azar. Diagnosis of PKDL presents a challenge due to the low parasite burden in the lesions. The direct agglutination test (DAT) based on promastigote and amastigote antigens of Leishmania donovani of indigenous isolates was developed to diagnose PKDL, and the results were compared with those of the rk39 strip test. The sensitivities of DAT for antileishmanial antibody detection, based on promastigote and amastigote antigens at a cutoff titer of 1:800 were 98.5% and 100%, respectively, with corresponding specificities of 96.5% and 100%. DAT could correctly detect 100% polymorphic cases and 95.4% macular PKDL cases. In comparison, the rk39 strip test was able to correctly diagnose 95.6% of polymorphic and 86.0% macular PKDL cases. DAT based on axenic amastigote antigen provided 100% sensitivity and specificity, making it particularly useful for macular PKDL cases, which are often missed by the rk39 strip test. Thus, DAT provides a simple, reliable, and inexpensive test for PKDL diagnosis with potential applicability in field conditions.
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Affiliation(s)
- Ruchi Singh
- Institute of Pathology (ICMR), New Delhi 110029, India
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Sreenivas G, Ansari NA, Kataria J, Salotra P. Nested PCR assay for detection of Leishmania donovani in slit aspirates from post-kala-azar dermal Leishmaniasis Lesions. J Clin Microbiol 2004; 42:1777-8. [PMID: 15071047 PMCID: PMC387583 DOI: 10.1128/jcm.42.4.1777-1778.2004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A nested PCR assay to detect parasite DNA in slit aspirates from skin lesions of patients with post-kala-azar dermal lesihmaniasis (PKDL) is described. PCR results were positive in 27 of 29 (93%) samples by nested PCR assay, while only 20 of 29 (69%) were positive in a primary PCR assay. The nested PCR assay allowed reliable diagnosis of PKDL in a noninvasive manner.
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Salotra P, Sreenivas G, Beena KR, Mukherjee A, Ramesh V. Parasite detection in patients with post kala-azar dermal leishmaniasis in India: a comparison between molecular and immunological methods. J Clin Pathol 2003; 56:840-3. [PMID: 14600129 PMCID: PMC1770099 DOI: 10.1136/jcp.56.11.840] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2003] [Indexed: 11/03/2022]
Abstract
AIMS To evaluate the sensitivity and specificity of serological, immunohistochemical, and molecular methods in the diagnosis of post kala-azar dermal leishmaniasis (PKDL). METHODS Twenty five patients with confirmed PKDL and 25 controls were included in the study. G2D10, a monoclonal antibody against Leishmania, was used for the immunohistochemical (IHC) staining of lesion sections to visualise anti-Leishmania donovani antibodies. The diagnostic usefulness of IHC was compared with enzyme linked immunosorbent assay (ELISA) with a recombinant (rk39) antigen, and a species specific polymerase chain reaction (PCR) assay, amplifying a kinetoplast minicircle DNA sequence. RESULTS IHC detected 22 of 25 PKDL cases, giving a sensitivity of 88%. The diagnostic sensitivity of both the ELISA and PCR tests was higher (96%). All of the 25 controls examined were negative in PCR, indicating 100% specificity of the test, whereas ELISA showed 96% specificity. CONCLUSIONS IHC with G2D10 significantly enhances the sensitivity of detection of PKDL over routine haematoxylin and eosin staining. ELISA with a recombinant antigen is an economical and practical assay. PCR is the most sensitive and specific diagnostic method for PKDL. The tests described would facilitate the recognition of patients with PKDL, enabling timely treatment, which would contribute greatly to the control of kala-azar.
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Affiliation(s)
- P Salotra
- Molecular Biology Laboratory, Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi-110 029, India.
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Beena KR, Ramesh V, Mukherjee A. Identification of parasite antigen, correlation of parasite density and inflammation in skin lesions of post kala-azar dermal leishmaniasis. J Cutan Pathol 2003; 30:616-20. [PMID: 14744086 DOI: 10.1034/j.1600-0560.2003.00125.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Post kala-azar dermal leishmaniasis (PKDL) is an unusual dermatosis following kala-azar (KA). Demonstration of the amastigotes in lesions plays an important role in the diagnosis of PKDL. It was aimed to evaluate the utility of an antibody G2D10 in detecting leishmania parasite antigen, to correlate the parasite number/percentage of parasites with the inflammation, and to assess the epidemiological significance associated with the location of the parasites. MATERIAL AND METHODS The study was conducted on 50 cases. Hematoxylin and eosin (H & E) stains and immunohistochemical (IHC) stains, using G2D10 antibody, was performed on the skin biopsies. The number of parasites and density of inflammation were semiquantitatively assessed. RESULTS Leishmania donovan bodies (LDBs) were identified in 50% of cases with the H & E compared to 80% positivity with the IHC. All 50 cases showed inflammation in the superficial dermis (SD). About 44% showed dense inflammation compared to 16% sparse and 40% moderate inflammation. Parasite percentage was maximum in the SD (100%) compared to 75 and 42% in the mid and deep dermis, respectively. CONCLUSIONS The IHC showed a higher percentage of LDB localization (80 vs. 50%). Density of inflammation was maximum in the SD. The parasite percentage was correlated with the inflammation. Location of parasites could have an epidemiological significance.
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Affiliation(s)
- K R Beena
- Institute of Pathology, Safdarjang Hospital Campus, New Delhi, India. beena_ram.hotmail.com
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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: 356] [Impact Index Per Article: 17.0] [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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Salotra P, Sreenivas G, Nasim AA, Subba Raju BV, Ramesh V. Evaluation of enzyme-linked immunosorbent assay for diagnosis of post-kala-azar dermal leishmaniasis with crude or recombinant k39 antigen. CLINICAL AND DIAGNOSTIC LABORATORY IMMUNOLOGY 2002; 9:370-3. [PMID: 11874880 PMCID: PMC119938 DOI: 10.1128/cdli.9.2.370-373.2002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The diagnosis of post-kala-azar dermal leishmaniasis (PKDL), a dermatosis that provides the only known reservoir for the parasite Leishmania donovani in India, remains a problem. Timely recognition and treatment of PKDL would contribute significantly to the control of kala-azar. We evaluated here the potential of the enzyme-linked immunosorbent assay (ELISA) as a diagnostic tool for PKDL. Antigen prepared from promastigotes and axenic amastigotes with parasite isolates that were derived from skin lesions of a PKDL patient gave sensitivities of 86.36 and 92%, respectively, in the 88 PKDL cases examined. The specificity of the ELISA test was examined by testing groups of patients with other skin disorders (leprosy and vitiligo) or coendemic infections (malaria and tuberculosis), as well as healthy controls from areas where this disease is endemic or is not endemic. A false-positive reaction was obtained in 14 of 144 (9.8%) of the controls with the promastigote antigen and in 14 of 145 (9.7%) of the controls with the amastigote antigen. Evaluation of the serodiagnostic potential of recombinant k39 by ELISA revealed a higher sensitivity (94.5%) and specificity (93.7%) compared to the other two antigens used. The data demonstrate that ELISA with crude or recombinant antigen k39 provides a relatively simple and less-invasive test for the reliable diagnosis of PKDL.
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Affiliation(s)
- P Salotra
- Molecular Biology Lab, Institute of Pathology (ICMR), Safdarjung Hospital, New Delhi 110-029, India.
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Salotra P, Sreenivas G, Pogue GP, Lee N, Nakhasi HL, Ramesh V, Negi NS. Development of a species-specific PCR assay for detection of Leishmania donovani in clinical samples from patients with kala-azar and post-kala-azar dermal leishmaniasis. J Clin Microbiol 2001; 39:849-54. [PMID: 11230394 PMCID: PMC87840 DOI: 10.1128/jcm.39.3.849-854.2001] [Citation(s) in RCA: 134] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We have developed a PCR assay that is capable of amplifying kinetoplast DNA (kDNA) of Leishmania donovani in a species-specific manner among Old World leishmanias. With Indian strains and isolates of L. donovani the assay was sensitive enough to detect kDNA in an amount equivalent to a single parasite or less. The extreme sensitivity of the assay was reflected in its ability to detect parasite DNA from small volumes of peripheral blood of patients with kala-azar (KA) and from skin lesions from patients with post-KA dermal leishmaniasis (PKDL). A total of 107 clinical leishmaniasis samples were analyzed. Of these 102 (95.3%) were positive by PCR. The test provided a diagnosis of KA with 96% sensitivity using patient whole-blood samples instead of bone marrow or spleen aspirates that are obtained by invasive procedures. The assay was also successful in the diagnosis of 45 of 48 PKDL cases (93.8%). Cross-reactions with pathogens prevalent in the area of endemicity, viz., Mycobacterium tuberculosis, Mycobacterium leprae, and Plasmodium spp., could be ruled out. Eighty-one control samples, including dermal scrapings from healthy portions of skin from patients with PKDL were all negative. Two of twenty controls from the area of endemicity were found positive by PCR assay; however, there was a good possibility that these two were asymptomatic carriers since they were serologically positive for KA. Thus, this PCR assay represents a tool for the diagnosis of KA and PKDL in Indian patients in a noninvasive manner, with simultaneous species identification of parasites in clinical samples.
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Affiliation(s)
- P Salotra
- Molecular Biology Lab, Institute of Pathology (ICMR), Safdarjung Hospital Campus, Poat Box #4909, Safdarjung Hospital, New Delhi 110 029, India.
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Abstract
BACKGROUND Post-kala-azar dermal leishmaniasis (PKDL) manifests as a skin eruption after healing of visceral leishmaniasis (VL), either spontaneously or as a result of treatment. This study was undertaken to describe the demographic, clinical, and histopathologic features of PKDL in Nepal. METHODS Demographic, clinical, microbiologic, and histopathologic features and response to treatment were studied in 22 patients with PKDL from April 1998 to March 2000. RESULTS PKDL accounted for 0.13% of all new dermatologic cases. There were 13 (59.1%) males and nine (40.9%) females. A past history of kala-azar was present in all but one patient. A family history of kala-azar was noted in eight (36.4%) patients. All patients presented with multiple types of lesion, except for two in whom only macular lesions were seen. Oral lesions in the form of nodules and plaques were seen in four patients. Generalized lymphadenopathy was present in five patients. Slit skin smears revealed Leishman-Donovan bodies (LDBs) in nine (40.9%) patients. In macular lesions, there was a sparse infiltrate of plasma cells, lymphocytes, or histiocytes in the upper dermis. There was a dense chronic inflammatory infiltrate comprising plasma cells, lymphocytes, histiocytes, and epithelioid cells in the entire dermis from papules, plaques, or nodules. Giemsa staining of biopsy specimens revealed LDBs in seven (38.9%) patients only. Fine needle aspiration from epitrochlear lymph nodes in two patients demonstrated LDBs. All patients responded well to treatment with minimal side-effects. CONCLUSIONS This study emphasizes the need to be aware of the possibility of cases of PKDL in endemic regions of leprosy, as the conditions may be difficult to distinguish clinically and histopathologically.
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Affiliation(s)
- V K Garg
- Department of Dermatology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal.
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Affiliation(s)
- D R Mehregan
- Pinkus Dermatopathology Laboratory, Monroe, Michigan 48161, USA
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Salotra P, Raina A, Ramesh V. Western blot analysis of humoral immune response to Leishmania donovani antigens in patients with post-kala-azar dermal leishmaniasis. Trans R Soc Trop Med Hyg 1999; 93:98-101. [PMID: 10492802 DOI: 10.1016/s0035-9203(99)90197-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Sera from 32 Indian patients with post-kala-azar dermal leishmaniasis (PKDL) were examined for antibodies by immunoblot analysis using an antigen extract of Leishmania donovani. The study revealed that the humoral immune response in PKDL patients was quite distinct compared to that in kala-azar patients. Antibodies to 3 antigens of L. donovani (molecular sizes 110, 65 and 38-42 kDa) were predominant in a majority (78%) of PKDL patients. The most important finding was the consistent recognition of 2 parasite antigens (of 110 and 65 kDa) by PKDL sera; antibodies to the 110-kDa antigen were detectable in 97% of cases, while antibodies to the 65-kDa antigen were detectable in 100% of cases that were examined. None of the 18 cases of leprosy, 10 of vitiligo, or the 30 healthy persons included in the study showed antibodies to these 2 antigens. Thus Western blot analysis provided a highly sensitive test for PKDL patients. Further, it led to the identification of 2 parasite antigens (110 and 65 kDa) that elicit an antibody response in 97-100% of PKDL patients. Purified or recombinant versions of these proteins deserve consideration as potential target antigens in development of simpler, highly specific and sensitive serodiagnostic tests for PKDL.
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Affiliation(s)
- P Salotra
- Molecular Biology Laboratory, Institute of Pathology (ICMR), Safdarjung Hospital, New Delhi, India.
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Roustan G, Jiménez JA, Gutiérrez-Solar B, Gallego JL, Alvar J, Patrón M. Post-kala-azar dermal leishmaniasis with mucosal involvement in a kidney transplant recipient: treatment with liposomal amphotericin B. Br J Dermatol 1998; 138:526-8. [PMID: 9580814 DOI: 10.1046/j.1365-2133.1998.02139.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Post-kala-azar dermal leishmaniasis (PKDL) is a rare clinical variant of cutaneous leishmaniasis. It is very common in the Indian subcontinent and less frequent in East Africa, but exceptional in the American and European continents. We have observed a case of PKDL in a renal transplant recipient. No systemic symptoms were present. The patient was treated with liposomal amphotericin B. We emphasize the unusual aspects of this case: the appearance of PKDL in Europe, its relationship with immunosuppression, the severe mucosal involvement and the excellent response to liposomal amphotericin B, a newly described treatment for the disease.
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Affiliation(s)
- G Roustan
- Department of Dermatology, Hospital Puerta de Hierro, Madrid, Spain
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Affiliation(s)
- V Ramesh
- Department of Dermatology, Safdarjang Hospital, New Delhi, India
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