Blindness following visceral leishmaniasis: a neglected post-kala-azar complication

Infectious eye disease in the 21st century-an overview

Infectious diseases affecting the eye often cause unilateral or asymmetric visual loss in children and people of working age. This group of conditions includes viral, bacterial, fungal and parasitic diseases, both common and rare presentations which, in aggregate, may account for a significant portion of the global visual burden. Diagnosis is frequently challenging even in specialist centres, and many disease presentations are highly regional. In an age of globalisation, an understanding of the various modes of transmission and the geographic distribution of infections can be instructive to clinicians. The impact of eye infections on global disability is currently not sufficiently captured in global prevalence studies on visual impairment and blindness, which focus on bilateral disease in the over-50s. Moreover, in many cases it is hard to differentiate between infectious and immune-mediated diseases. Since infectious eye diseases can be preventable and frequently affect younger people, we argue that in future prevalence studies they should be considered as a separate category, including estimates of disability-adjusted life years (DALY) as a measure of overall disease burden. Numbers of ocular infections are uniquely affected by outbreaks as well as endemic transmission, and their control frequently relies on collaborative partnerships that go well beyond the remit of ophthalmology, encompassing domains as various as vaccination, antibiotic development, individual healthcare, vector control, mass drug administration, food supplementation, environmental and food hygiene, epidemiological mapping, and many more. Moreover, the anticipated impacts of global warming, conflict, food poverty, urbanisation and environmental degradation are likely to magnify their importance. While remote telemedicine can be a useful aide in the diagnosis of these conditions in resource-poor areas, enhanced global reporting networks and artificial intelligence systems may ultimately be required for disease surveillance and monitoring.

Unusual Observations in Leishmaniasis-An Overview

Leishmaniasis significantly affects the population of the tropics and subtropics. Clinical features and infective species of Leishmania are the primary factors driving the direction of diagnosis. The rise in incidences of atypical presentations present a challenge in patient treatment. Knowledge of unusual/rare presentations can aid in having a broader perspective for including the different aspects during the examination and thus avoid misdiagnosis. A comprehensive literature survey was performed to present the array of atypical presentations confounding clinicians which have been seen in leishmaniasis. Case reports of unusual findings based on the localizations and morphology of lesions and infective species and the predominant geographical sites over almost five decades highlight such presentations in the population. Information regarding the clinical features recorded in the patient and the chosen treatment was extracted to put forward the preferred drug regimen in such cases. This comprehensive review presents various unusual observations seen in visceral leishmaniasis, post-kala-azar dermal leishmaniasis, cutaneous leishmaniasis, and mucocutaneous leishmaniasis. It highlights the need to consider such features in association with differential diagnosis to facilitate proper treatment of the patient.

Immune recovery-related patterns of post kala-azar dermal and ocular leishmaniasis in people living with HIV

OBJECTIVE

Post kala-azar dermal leishmaniasis (PKDL) is a rare complication of visceral leishmaniasis. We aimed at reporting PKDL cases in people living with HIV (PLHIV) and compare their characteristics based on whether PKDL occurred in the context of immune recovery under antiretroviral therapy (ART) or not.

DESIGN

National survey and literature review.

METHODS

We called for observations in France in October 2020 and performed a literature review from PubMed (Medline) and Web of Science up to December 2020. Two groups of patients were defined based on whether PKDL occurred in the context of immune recovery under ART (group 1) or not (group 2), and compared.

RESULTS

Three PLHIV with PKDL identified in France in the last decade were described and added to 33 cases from the literature. Compared with group 2 (16/36, 44.4%), patients from group 1 (20/36, 55.6%) originated more frequently from Europe (12/20, 60% vs. 2/16, 12.5%; P  = 0.0038), had higher median blood CD4 + cell counts (221/μl vs. 61/μl; P  = 0.0005) and increase under ART (122/μl, interquartile range 73-243 vs. 33/μl, interquartile range 0-53; P  = 0.0044), had less frequently concomitant visceral leishmaniasis (3/20, 15% vs. 8/12, 66.7%; P  = 0.006), and a trend to more frequent ocular involvement (7/20, 35% vs. 1/16, 6.25%; P  = 0.0531).

CONCLUSION

In PLHIV, PKDL occurs after a cured episode of visceral leishmaniasis as part of an immune restoration disease under ART, or concomitant to a visceral leishmaniasis relapse in a context of AIDS. For the latter, the denomination 'disseminated cutaneous lesions associated with visceral leishmaniasis' seems more accurate than PKDL.

[Generalized old world leishmaniasis: first Moroccan case in an immunocompetent adult?]

BACKGROUND

Post-kala-azar dermal Leishmaniasis (PKDL) is a rare skin syndrome observed after treatment of visceral Leishmaniasis (VL) with pentavalent antimonial organic salts, never described in Morocco before. Here we report a case in an immunocompetent adult.

CASE

A 36-year-old-man from Tata in southern Morocco, with a history of visceral Leishmaniasis 2 years before and treated with meglumine antimoniate and amphotericin B with good clinical course, was hospitalized in dermatology for an erythematous papulo-nodular closet of the face. Six months ago, he presented oral mucosa involvement, then 3 months later, cutaneous lesions appeared on the face. The dermatological examination revealed a papulo-nodular erythematous closet extending to the nose and both cheeks, crusty and lupoid lesions on the forehead, around the eyes and chin, associated with an ulcerative and painless lesion on the heeL. The examination of the oral mucosa revealed an ulceration of the posterior third of the tongue and a papillomatous aspect of the soft palate. The skin biopsy and smear found some amastigote forms of Leishmania bodies. ITS1 PCR was positive (genus Leishmania). The HIV serology was negative. The diagnosis of PKDL was then evoked. The patient received intra-muscular injections of meglumine antimoniate with good progress.

CONCLUSION

To our knowledge, this is the first case of generalised leishmaniasis suggesting PKDL reported in a Moroccan immunocompetent adult.

Ocular Leishmaniasis - A systematic review

The incidence of leishmaniasis is reported to be up to 1 million per year. To date, there has been no comprehensive review describing the diversity of clinical presentations of ocular leishmaniasis (OL) and its treatment. This systematic review aims to address this knowledge gap and provide a summary of the clinical presentation, natural course, and treatment options for OL. Our study identified a total of 57 published articles as describing cases of OL involving: adnexa (n = 26), orbit (n = 1), retina (n = 7), uvea (n = 18) and cornea (n = 6). Though well described and easily treated, palpebral leishmaniasis is often misdiagnosed and may lead to chronic issues if untreated. The retinal manifestations of Leishmaniasis consist of self-resolving hemorrhages secondary to thrombocytopenia. Two main uveitis etiologies have been identified: uveitis in the context of active Leishmanial infection (associated with immunosuppression) and uveitis occurring as an immune reconstitution syndrome. Corneal involvement in most geographic areas generally follows an aggressive course, most often ending in corneal perforation if left untreated. In the Americas, a chronic indolent interstitial keratitis may also occur. Topical steroids are of little use in keratitis (systemic antileishmanials being the cornerstone of treatment). However, these are essential in cases of uveitis, with or without concomitant systemic antileishmanial therapy. In conclusion, though ocular involvement in Leishmaniasis is rare, severe sight-threatening consequences follow if left untreated. Early diagnosis, enthusiastic follow-up and aggressive treatment are essential for good outcomes.

Atypical Presentation of Post-Kala-Azar Dermal Leishmaniasis in Bhutan

This article describes an atypical case of post-kala-azar dermal leishmaniasis associated with complications due to delayed diagnosis and poor case management. The grave consequences of the prolonged disease process that continued for over 2 decades with eventual healing included facial disfigurement, visual impairment, and mental distress both to the patient and the family. The persistent infection within the skin over a lengthy period with likely increased risk of infection spread in the community highlights its potential negative impact on the ongoing leishmaniasis elimination program in the Indian subcontinent. Bhutan is a member of the leishmaniasis elimination network in Asia, and the government continues to invest in maintenance of the national healthcare system. The case study reveals the gaps in the healthcare system with hardships faced by a patient to access quality healthcare and poor patient outcome used as proxy indicators. It also points to the need to enhance access to healthcare to ensure early diagnosis and effective treatment for leishmaniasis patients including those who live in remote areas, in order to achieve the planned disease elimination targets. It also points towards the key challenges faced by a resource poor nation such as Bhutan in achieving universal health coverage and reaching the set goals for disease elimination. The findings underscore the need for a careful review of the national health care system and to address the deficiencies.

Corneal complications following Post Kala-azar Dermal Leishmaniasis treatment

Post Kala-azar Dermal Leishmaniasis (PKDL) is a sequel of Visceral Leishmaniasis (VL). The patients act as a reservoir for the causative parasite (i.e. Leishmania donovani) and thus should be diagnosed and treated with the utmost urgency to prevent the transmission of the disease. In this study, we tried to report the first instances of corneal complications supposedly associated with Miltefosine (MF), in PKDL patients and the probable pathophysiology of such events. The recently rejuvenated National Kala-azar Elimination Program in Bangladesh has put great emphasis on monitoring all the leishmaniasis patients to investigate possible adverse drug reactions (ADR). A total of 194 patients have received Miltefosine for the treatment of Post Kala-azar Dermal Leishmaniasis. So far five patients were found to have developed unilateral ophthalmic complications during the periods from May 2016 to October 2017, after being treated with MF for PKDL. Unfortunately, one of whom had to go through complete evisceration of the affected eyeball. Despite the fact that MF is the only oral formulation of choice to treat PKDL, occurrences of such unexpected ADRs after MF administration urges the exploration of the pathogenesis of such incidents and determine measures to avert such occurrences from happening in future.

[International ophthalmology and travel medicine]

Medical eye care in developing countries is very different from the situation in industrialized nations. In order to prevent rising numbers of blind people worldwide due to increased life expectancy and population growth, the global initiative Vision 2020 "The Right to Sight" was established in 1999. Coordinated initiatives are important as most causes of blindness are either preventable or curable (e.g. cataract surgery); however, due to a lack of resources eye care in developing countries cannot implement all necessary preventive and therapeutic measures at present. The epidemiology of causes of blindness and the situation of ophthalmic care are discussed. Because of increased mobility of people and goods (e.g. air travel and trucking), imported eye diseases are of increasing importance. The difference between travel medicine, which deals with the medical situation of travelers and international ophthalmology (i.e. diseases in tropical countries) is discussed and illustrated on the basis of several important disease patterns.

Ocular parasitoses: A comprehensive review

Parasitic infections of the eyes are a major cause of ocular diseases across the globe. The causative agents range from simple organisms such as unicellular protozoans to complex metazoan helminths. The disease spectrum varies depending on the geographic location, prevailing hygiene, living and eating habits of the inhabitants, and the type of animals that surround them. They cause enormous ocular morbidity and mortality not because they are untreatable, but largely due to late or misdiagnosis, often from unfamiliarity with the diseases produced. We provide an up-to-date comprehensive overview of the ophthalmic parasitoses. Each section describes the causative agent, mode of transmission, geographic distribution, ocular pathologies, and their management for common parasites with brief mention of the ones that are rare.

The immunology of post-kala-azar dermal leishmaniasis (PKDL)

Post-kala-azar dermal leishmaniasis (PKDL) is a common complication of visceral leishmaniasis (VL) caused by Leishmania donovani. Because of its possible role in transmission it is considered a public health problem in VL endemic areas. The clinical features include a skin rash consisting of macules, papules or nodules in an otherwise healthy individual; this presentation is determined by the immune response towards parasites in the skin that probably persisted from the previous VL episode. The immune response in VL, cured VL and PKDL is the result of changes in the cytokine profile that only in part can be captured under the Th1 and Th2 dichotomy. Regulatory T cells and Th 17 cells also play a role. VL is characterized by an absent immune response to Leishmania with a predominantly Th2 type of response with high levels of IL-10; after successful treatment the patient will be immune with in vitro features of a Th1 type of response and in vivo a positive leishmanin skin test. PKDL takes an intermediate position with a dissociation of the immune response between the skin and the viscera, with a Th2 and Th1 type of response, respectively. It is likely that immune responses determine the different epidemiological and clinical characteristics of PKDL in Asia and Africa; various risk factors for PKDL may influence this, such as incomplete and inadequate treatment of VL, parasite resistance and genetic factors. It should be noted that PKDL is a heterogeneous and dynamic condition and patients differ with regard to time of onset after visceral leishmaniasis (VL), chronicity, extent and appearance of the rash including related immune responses, all of which may vary over time. Better understanding of these immune responses may offer opportunities for manipulation including combined chemotherapy and immunotherapy for VL to prevent PKDL from occurring and similarly in the treatment of chronic or treatment resistant PKDL cases.

Uveitis secondary to leishmaniasis immune reconstitution syndrome in a HIV-positive patient

We describe the case of a HIV-positive patient treated for visceral leishmaniasis who developed uveitis as part of a leishmaniasis immune reconstitution syndrome. Visceral leishmaniasis is increasingly found in HIV-positive adults. Its ophthalmic manifestations can range from relatively minor to complicated anterior uveitis, leading to secondary glaucoma and loss of vision. Clinicians caring for people living with HIV should be alert to the complications of leishmaniasis that can occur before and during treatment.

A case of panuveitis with hypopyon due to presumed ocular leishmaniasis in a HIV patient

Background

Post-kala-azar dermal leishmaniasis is a well-known immunologic cutaneous reaction. There are few case reports of ocular leishmaniasis. It is a sight-threatening condition that needs to be rapidly recognized and treated to avoid permanent visual loss. Ocular leishmaniasis panuveitis can present with severe inflammation in patients with highly active anti-retroviral therapy (HAART)-induced immune reconstitution syndrome.

Findings

A case of a 40-year-old man, human immunodeficiency virus (HIV) positive on HAART, with a presumed diagnosis of ocular leishmaniasis, is presented. He had a past history of visceral leishmaniasis and was referred to the uveitis service with rapidly worsening panuveitis and counting fingers vision in both eyes. On empirical anti-leishmania therapy and systemic steroids, the visual acuity of the left eye improved to 6/9 but remained poor in the right eye. Based on the medical history, improvement with therapy and the exclusion of other common infections, a presumed diagnosis of ocular leishmaniasis-related panuveitis was made.

Conclusions

A major immune reaction against lingering parasites may play a key role in the pathogenesis of this sight-threatening and rapidly progressive condition. Both the infection and the immune reaction should be treated.

Electronic supplementary material

The online version of this article (doi:10.1186/s12348-014-0021-0) contains supplementary material, which is available to authorized users.

[Recurrent bilateral anterior uveitis due to Leishmania infantum in a patient with immune deficiency related to HIV infection: a case report and literature review]

We report the case of a 56-year-old patient, presenting with bilateral hypertensive anterior uveitis due to Leishmania infantum, in the setting of immune deficiency related to HIV infection. The etiology of the uveitis was diagnosed following detection of L. infantum DNA on anterior chamber paracentesis. Initially, the patient received an intravitreal injection of liposomal amphotericin B, systemic antiparasitic treatment, topical steroid and ocular hypotensive treatment. Due to unfavourable disease progression in the right eye, we re-evaluated the anti-inflammatory, antiretroviral and antiparasitic medications (beginning meglumine antimoniate): the uveitis in the left eye was thus able to be controlled. We followed the efficacy of treatment with weekly quantification of Leishmania DNA in the aqueous humor. Uveitis secondary to leishmaniasis is rare and serious. Physicians must be aware of this cause of uveitis, particularly in immunodeficient patients. The quantitation of Leishmania DNA in the aqueous humor is an indispensible tool for monitoring the disease.

Ocular experimental leishmaniasis in C57BL/10 and BALB/c mice induced by Leishmania amazonensis infection

There are few studies on human ocular leishmaniasis found in the literature. The purpose of this study was to describe experimental ocular leishmaniasis, caused by Leishmania amazonensis evaluating two different infection routes: intravitreal and instillation in C57BL/10 and BALB/c mice. In this work all animals presented low anti-Leishmania IgM and IgG titers regardless of the infection route or mouse strain. The histopathological eye analysis showed that the mice inoculated by the intravitreal route developed more severe lesions, presenting parasites in the anterior region of the eye 60 days after infection. The C57BL/10 mice presented cells containing parasitophorous vacuoles associated with pigmented cells and inflammatory infiltrate, which included mast cells. Ninety days after infection no parasites could be found in either mouse strain, which led us to hypothesize that parasites had been eliminated. In this context, we show that both intravitreal and instillation routes were effective in promoting ocular leishmaniasis infections in C57BL/10 and BALB/c mice. There were no differences in the parasite infection between the two mouse models and it mimicked the ocular lesions described in symptomatic dogs in endemic areas of visceral leishmaniasis.