Human Cutaneous Leishmaniosis in Iran, Up to Date-2019

Geographical and climatic risk factors of cutaneous leishmaniasis in the hyper-endemic focus of Bam County in southeast Iran

Introduction

Cutaneous leishmaniasis (CL) is a prevalent debilitating disease in many countries, particularly in Iran, the Middle East, North Africa, and South America. Bam County is the most important highly endemic focus of anthropometric CL in Iran and has been under consideration by WHO. This study investigated the environmental and geographic factors affecting the occurrence and distribution of CL in this focus.

Methods

Demographic data and the home addresses of CL patients diagnosed from 2015 to 2020 were retrieved from the Leishmaniasis Center of Bam in southeast Iran. The effects of mean annual rainfall (MAR), mean annual humidity (MAH), mean annual temperature (MAT), maximum annual temperature (MaxMAT), minimum annual temperature (MinMAT), mean annual humidity (MAH), mean annual evaporation (MAE), mean annual frosty days (MAFD), mean annual snowy hours (MASH), elevation, and land cover on the distribution of CL were analyzed using geographical information systems (GIS) and univariate and multivariate regression models.

Results

Of 847 patients studied, 50.9% (n = 431) were female and 49.1% (n = 416) were male. The age classes 0-10 (n = 246) and 11-20 (n = 145) showed the highest frequency of patients, respectively. Leishmaniasis patients were reported from 66 villages/cities (11.8%) out of 561 residential areas in Bam County. Univariate analysis showed that urban settings (OR = 21.66), agriculture (OR = 5.73), orchards (OR = 5), salty land (OR = 1.05), and temperatures (OR = 2.37, 2.79 and 3.47) had positive effects on CL occurrence (p < 0.05), while altitude, precipitation, humidity, evaporation, and the number of frozen days had negative effects. Multivariate analysis identified urban settings (OR = 13.6), orchards (OR = 6.29), agriculture (OR = 5.82), and minimum temperature (OR = 2.38) as the most significant determinants of CL occurrence in this region.

Conclusion

Environmental and ecological factors play an important role in the distribution of CL in Bam County. The high-risk zones for CL are cities/large villages, agricultural and orchard areas in lower altitudes and with warmer climates and lower rainfall and humidity. This model can guide researchers and health managers to properly conduct CL control programs and allocate budgets.

Amphotericin B-Loaded Extracellular Vesicles Derived from Leishmania major Enhancing Cutaneous Leishmaniasis Treatment through In Vitro and In Vivo Studies

Background

Recent studies have shown an increasing number of patients with cutaneous leishmaniasis (CL) who do not respond to pentavalent antimonials as the first line of treatment for CL. Nanocarriers such as extracellular vesicles (EVs) are efficient vehicles that might be used as drug delivery systems for the treatment of diseases. Therefore, we aimed to isolate and characterize the EVs of Leishmania major, load them with Amphotericin B (AmB), and investigate the toxicity and efficacy of the prepared drug form.

Methods

The EVs of L. major were isolated, characterized, and loaded with amphotericin B (AmB), and the EVs-Amphotericin B (EVs-AmB) form was synthesized. Relevant in vitro and in vivo methods were performed to evaluate the toxicity and efficacy of EVs-AmB compared to the control.

Results

The anti-leishmanial activity of the EVs-AmB showed a higher percentage inhibition (PI%) (P = 0.023) compared to the AmB at different concentrations and time points. Obtained data showed a significant increase in the lesion size and parasite load in the lesion, PBS, and EVs mice groups in comparison with EVs-AmB, AmB, and Glucantime groups (P < 0.05), EVs-AmB had a significant decrease in lesion sizes in comparison with AmB (P < 0.05). Results showed that EVs-AmB decreased its toxicity to the kidneys and liver (P < 0.05).

Conclusion

EVs-AmB improved the efficacy of AmB in mouse skin lesions and reduced hepatorenal toxicity. Furthermore, EVs could be a promising nanoplatform for the delivery of AmB in CL caused by L. major.

Field Efficacy of Topical Nano-Liposomal Amphotericin B (Sina Ampholeish®) Alone or in Combination with Glucantime® and Cryotherapy on Human Cutaneous Leishmaniasis

Background

Cutaneous leishmaniasis (CL) is a parasitic disease that presents a broad spectrum of clinical features. Treatment of CL is problematic. We aimed to compare the field therapeutic efficacy of topical nanoliposomes containing 0.4% amphotericin B (Nano Lip-AmB) alone and in combination with cryotherapy and/or Glucantime® on human CL in the endemic areas of Iran.

Methods

This retrospective study was performed based on the results of using Nano Lip-AmB alone or with Glucantime® and/or cryotherapy in the treatment of zoonotic cutaneous leishmaniasis (ZCL) in patients referred to health centers of Isfahan, Golestan and Ilam Provinces of Iran as endemic foci of ZCL caused by Leishmania major besides Mashhad and Bam cities as endemic foci of anthroponotic cutaneous leishmaniasis (ACL) caused by with L. tropica.

Results

Two hundred and seventy-eight patients with CL were included in the current study. All of the patients (100%) who received Nano Lip-AmB alone or in combination with Glucantime® and/or cryotherapy based on guideline of Iranian national committee for the treatment of CL. Two patients with 7 skin lesions, who was resident in ACL endemic area and received Nano Lip-AmB plus Glucantime® and another patient was a resident of ZCL endemic area and received Nano Lip-AmB plus cryotherapy showed clinical relapses after treatment.

Conclusion

Sina Ampholeish® in combination with other standard protocols of treatment of CL is well tolerated and with acceptable clinical efficacy rate.

Predicting current and future high-risk areas for vectors and reservoirs of cutaneous leishmaniasis in Iran

Climate change will affect the distribution of species in the future. To determine the vulnerable areas relating to CL in Iran, we applied two models, MaxEnt and RF, for the projection of the future distribution of the main vectors and reservoirs of CL. The results of the models were compared in terms of performance, species distribution maps, and the gain, loss, and stable areas. The models provided a reasonable estimate of species distribution. The results showed that the Northern and Southern counties of Iran, which currently do not have a high incidence of CL may witness new foci in the future. The Western, and Southwestern regions of the Country, which currently have high habitat suitability for the presence of some vectors and reservoirs, will probably significantly decrease in the future. Furthermore, the most stable areas are for T. indica and M. hurrianae in the future. So that, this species may remain a major reservoir in areas that are present under current conditions. With more local studies in the field of identifying vulnerable areas to CL, it can be suggested that the national CL control guidelines should be revised to include a section as a climate change adaptation plan.

The Accuracy of Diagnosis and Genotyping of Leishmania Species Based on Spliced Leader Mini-Exon Gene by Nuclear Magnetic Resonance and Sequencing Assays

Background

We aimed to evaluate the accuracy of genotyping of Leishmania species by the spliced leader mini-exon gene.

Methods

Suspected leishmaniasis patients, referred to Masieh Daneshvary Hospital, Tehran, Iran were included from May 2017 to September 2021. The Leishmania species were genotyped by PCRRFLP based on the SL mini-exon gene and the ITS1 region of SSU-rRNA gene and compared with the sequencing results. The expressed metabolites of metacyclic promastigotes were evaluated by Proton nuclear magnetic resonance (1H-NMR).

Results

Out of 66 suspected cases, 36 (54.4%) were positive for Leishmania species based on the PCR assays. In 21 (31.8%) cases, promastigotes grew on culture tubes. Based on the RFLP of SL RNA profile, 13 (19.7%) L. tropica, 9 (13.6%) L. major, 3 (4.5%) L. infantum, and 8 (12.1%) C. fasciculata isolates, isolated from culture media, were identified; however, 3 (4.5%) cases were unidentifiable due to the low number of parasites. Seventeen metabolites were expressed by the metacyclic forms of L. major, L. tropica and C. fasciculata isolates. The top differential metabolites expressed more in C. fasciculata were FAD, p-Methoxybenzyl alcohol and S-b-G-5, 5-G-b-S (A = CH2) (P<0.005) whereas Veratryl glycerols and D-(+)-Mannose were significantly increased in L. major and Betulin, LTyrosine in L. tropica (P<0.01).

Conclusion

The invaluable techniques such as sequencing and 1H-NMR confirmed the results of genotyping of Leishmania species based on the SL mini-exon gene. SL mini exon gene can be used as a diagnostic tool to differentiate various Leishmania genotypes and detect contamination of culture media with C. fasciculata.

Molecular Identification of Cutaneous Leishmaniasis Species in the Northcentral Iranian Province of Alborz: Is There a New Focus on Cutaneous Leishmaniasis in the Province?

Background

Cutaneous leishmaniasis (CL) is an endemic infection in the Middle East, including Iran that is also spreading to new foci. We aimed to determine the leishmaniasis species causing CL in Alborz province.

Methods

Overall, out of 55-suspected CL patients referred to health centers in Alborz Province, north central Iran in 2019, 40 patients had positive smear for CL based on optical microscopy. The internal transcribed spacer 1 (ITS1) of nuclear ribosomal DNA (rDNA) was amplified by PCR. Leishmania species were identified by PCR-restriction fragment length polymorphism (PCR-RFLP) using BshF I (Hae III) enzyme.

Results

Out of the 40 positive patients with CL, 34 cases (85%) had been caused by Leishmania (L) major and six (15%) by L. tropica. Fifteen patients had no history of traveling to the disease endemic areas, of which nine were Iranians. Skin lesions and scars caused by CL were mostly observed on the hands and face. Moreover, more than two skin lesions were observed in 22 cases (55%), all of which were infected with L. major. A single skin ulcer was seen in 18 (45%) of the CL patients.

Conclusion

Climate change, reduced rainfall, and demographic changes such as migration into Alborz Province and the increasing marginalization of the population and their entry to settle in new areas might have caused natural transmission of both L. tropica and L. major in this province.

The Therapeutic Effects of Curcumin-coated Gold Nanoparticle Against Leishmania Major Causative Agent of Zoonotic Cutaneous Leishmaniasis (ZCL): An In Vitro and In Vivo Study

We synthesized and characterized curcumin-coated gold nanoparticles (Cur@AuNPs) and investigated their stability, cytotoxicity, leishmanicidal activity in in vitro and in in vivo experiments. Cur@AuNPs synthesized through a simple one-pot green chemistry technique. The in vitro leishmanicidal activity of curcumin-coated gold nanoparticles against extracellular promastigotes and intracellular amastigotes of protozoan parasite Leishmania major (L. major) was determined by applying the tetrazolium reduction colorimetric quantitative MTT technique. For in vivo assessment, the footpad lesion size and parasite burden in two infection site organs including lymph nodes and footpads of susceptible BALB/c mice infected with L. major were measured. Mice immune responses in all study groups were quantified by measuring the levels of gamma interferon (IFN-γ) and interleukin-4 (IL-4). Viability of Leishmania promastigotes significantly diminished with the inhibition in promastigotes growth (IC₅₀) of 64.79 μg/mL and 29.89 μg/mL for 24 h and 48 h, respectively. In vitro nanoparticles treatment efficiently cleared the L. major amastigotes explanted in macrophages but had no harmful toxicity on the mice cells. In the in vivo condition, in the treated infected BALB/c mice the CL lesion size, Leishmania parasite burden, and IL-4 were decreased, while IFN-γ was significantly increased. The results suggest that Cur@AuNP was an effective compound against Leishmania parasite in vitro and in vivo, efficiently induced T-helper 1 (Th1) responses and augmented host cellular immune responses, and ending in a reduced Leishmania parasite burden. Therefore, it may be identified as a novel potential therapeutic approach for the local therapy of zoonotic CL treatment with high cure rates.

PCR-Based Diagnosis of Leishmania Species in Chronic Granulomatous Dermatitis in Mashhad, Iran

Background

Cutaneous leishmaniasis (CL) is a chronic granulomatous dermatitis (CGD). Approximately, 90% of CL patients are from seven countries including Iran. We explain polymerase chain reaction (PCR) diagnostic technique for chronic granulomatosis dermatoses including CL in Mashhad, Iran.

Methods

This study enrolled 64 patients within 2009-2013 with chronic granulomatosis dermatitis referred to dermatology and pathology departments of Imam Reza Hospital, affiliated to Mashhad University of Medical Sciences (MUMS), Mashhad, Iran. We gathered demographic data from archived folders. Histological light microscopic evaluation and parasitological tests were done on selected specimens. We used PCR diagnostic test on specimens. Statistical analysis was done by SPSS version 15.

Results

Generally, 7 out of 64 specimens had Leishmania DNA and other samples had no Leishmania DNA. The mean age of patients was 46 ± 18.77 years; disease duration was 7 ± 6.73 months ranging from 1-24 months. Most of the lesions were located on face and upper limb. Totally, 5 out of 7 samples were Leishmania major and 2 out of 7 samples were L. tropica. Tuberculoid granuloma was present in L. tropica samples and 3 of L. major samples. Other light microscopic changes were as follow: 42 suppurative granuloma, and epidermal changes including atrophy, pseudoepitheliomatous hyperplasia, and parakeratosis with dermal changes including, plasma cell, involvement of papillary and reticular dermis, and distribution of granuloma to hypodermis.

Conclusion

Our results addressed PCR-based diagnosis of chronic cutaneous leishmaniasis, which is resulted from L. major and L. tropica.