Childhood cutaneous leishmaniasis: report of 117 cases from Iran

Epidemiological survey, molecular profiling and phylogenetic analysis of cutaneous leishmaniasis in Khyber Pakhtunkhwa, Pakistan

BACKGROUND

Cutaneous leishmaniasis (CL), an emerging vector-borne ailment in Khyber Pakhtunkhwa (KPK), Pakistan, exhibits diverse spread patterns and outbreaks.

METHODS

To comprehend its epidemiology and identify parasite species, we conducted an active survey on suspected CL cases (n=8845) in KPK.

RESULTS

Microscopy and internal transcribed spacer-1 PCR-restriction fragment length polymorphism (RFLP) molecular techniques detected Leishmania spp. in blood samples. Phylogenetic analysis gauged genetic affinities with other areas. District Bannu displayed the highest CL impact (14.58%), while Swat had the lowest impact (4.33%) among cases. Annual blood examination rate, parasite incidence and slide positivity rate were 4.96 per 1000 people, 0.0233 and 0.047%, respectively. CL infections were prevalent in 1- to 20-y-olds, with males (57.17%) more vulnerable than females (42.82%). Single lesions occurred in 43.73% of patients, while 31.2% people had two lesions, 17.31% had three lesions and 7.74% had more than three lesions. Most had sand-fly exposure but lacked preventive measures like repellents and bed nets. Leishmania tropica was confirmed via RFLP analysis in amplified samples. Phylogenetic analysis unveiled genetic parallels between L. tropica of KPK and isolates from China, Iran, Afghanistan, India, Syria and Morocco.

CONCLUSIONS

Urgent comprehensive control measures are imperative. Early detection, targeted interventions and raising awareness of CL and sand-fly vectors are vital for reducing the disease's impact. International collaboration and monitoring are crucial to tackle Leishmania spp.'s genetic diversity and curtail its cross-border spread.

Prevalence of cutaneous Leishmaniasis in the Middle East: a systematic review and meta-analysis

Cutaneous leishmaniasis (CL), caused by an obligate intracellular protozoan parasite from the genus Leishmania, imposing a significant burden on underdeveloped countries especially those located in the Middle East. Four electronic databases were searched to evaluate the prevalence of CL in the Middle East. The random effects model (95% confidence intervals (CI)) were applied to determine the overall and subgroup pooled prevalence. Heterogeneity was assessed by Cochran's Q test and I2 statistics. Among 2424 peer-reviewed papers, 37 datasets from 34 studies were included in the current meta-analysis. 285560 individuals were assessed across 9 Middle Eastern countries. The pooled prevalence of CL was estimated at 12% (95% CI 9-15 %; 10718/285560). The highest prevalence rate was observed in Syria (39%, 37-42%), and the lowest one was found in Iraq and Lebanon (0%, 0-1%). The prevalence of CL in studies that applied LST assays had the highest rate (48%, 17-80%). The infection rate in males was similar to females (7%, 4-10%). The prevalence of infection in individuals living in urban areas was higher than in rural areas (14%, 10-19%). The prevalence of CL in the age group 0-15 years was higher than in individuals 16-40 and >40 years (9%, 6-13%). Most of the lesions were found on the face, and single lesions were more prevalent than two and three ones. In conclusion, the occurrence of CL was considerable in Middle Eastern countries. Therefore, more efforts should be made to precisely report the CL in this region for developing appropriate preventive and controlling strategies.  .

Geographical distribution and molecular epidemiology of cutaneous leishmaniasis in Fars Province, southern Iran

Cutaneous leishmaniasis (CL) is one of the important zoonotic diseases in Iran, particularly in Fars Province, southern Iran. The purpose of this descriptive cross-sectional study was to investigate the molecular identification and geographical distribution of anthroponotic and zoonotic CL in southern Iran, during 2018-2019. Overall, 161 patients with CL referred to the Leishmaniasis Diagnostic Laboratory, Valfajr Health Center, Shiraz, Iran, were included in this study. The smears were prepared from the lesion borders of patients and stained with Giemsa and diagnosed microscopically. For molecular identification, the genomic DNA of each sample was extracted, and PCR method was used. The geographical distribution map was prepared using ArcMap software. Finally, the possible correlation between the frequencies of CL in various subgroups was statistically analyzed by Chi-square test, using SPSS software. Of 161 positive samples confirmed by both microscopy and PCR, 126 (78.3%) and 35 (21.7%) samples were shown to be L. major and L. tropica, respectively. Also, 87 (54%) patients were male, and 74 (46%) were female. The study showed that anthroponotic cutaneous leishmaniasis (ACL) was detected only in Shiraz city, while zoonotic cutaneous leishmaniasis (ZCL) was observed both in Shiraz and most counties of Fars Province. Furthermore, the most CL infections occurred in district 8 among the different districts of Shiraz municipality, which requires serious attention.

The Effects of Some Climate Factors upon Frequency Distribution of Local Sandflies Breed in Misan Province, Iraq

The genus Phlebotomus is naturally responsible for the transmission of many protozoal parasites like Leishmania. The study was conducted to determine the effect of some climate factors on sandflies distribution over a year from December 2019 to November 2020. A total of 268 sandflies of both sexes were collected from different areas in Misan province, Iraq. Sandflies were collected using light traps and stick oil paper, then placed in cups or Petri dishes containing sterile normal saline for examination. The current study showed an inverse relationship between the presence and number of sandflies with temperatures. Rainfall had a significant impact on parasite distribution, while wind speed had a potential impact on sandfly activity. The percentage of female sandflies was significantly (P<0.05) higher than that of males (54.85% for females versus 45.15% for males). In conclusion, heavy precipitation is the main climate factor that affects the frequency distribution of local breed sandflies followed by rising temperature degrees that are seen in the summer season. The climate can affect the activity, spreading, and distribution of sandflies with detected one peak of their activity in December.

Epidemiological and pathological characteristics of Cutaneous Leishmaniasis from Baluchistan Province of Pakistan

Cutaneous Leishmaniasis (CL) is considered a neglected tropical disease which in Pakistan can now be considered as a growing public health problem. The exact figures on the magnitude of the disease are lacking both at the national and regional level and only a few health centres are available for diagnosis of CL. The present study was designed to identify the epidemiology of CL infection from August 2018 to December 2019 and to assess clinical aspects of CL in Baluchistan Province of Pakistan. A total of 4072 clinically suspected CL cases were analysed statistically. The highest number of CL cases were reported in May, followed by April, January and then July, February and June and the lowest number of cases were observed in March and November. The highest prevalence rate was found in males where 38% of reported cases were aged 0-9 years. The majority (24.4%) of lesions were found on the hands followed by the face in which cheeks, ears and nose were the effected organs. About 50% of the participants have single lesion while 14% of the participants had two and nearly 3% of the participants have six lesions. The atypical clinical presentations were observed in Baluchistan and common unusual presentations were lupus erythematosus. The study findings suggest that more epidemiological studies and health education campaigns are needed for the population awareness regarding CL in Baluchistan. It is recommended that risk factors should be evaluated to establish control and management strategies to prevent disease at the individual and community level.

Clinical, microscopic and molecular presentation in pediatric versus adult old world cutaneous Leishmaniasis

BACKGROUND

Cutaneous leishmaniasis (CL) is an emerging uncontrolled tropical parasitic disease in endemic and nonendemic areas with a high prevalence in the pediatric age group.

METHOD

A total of 382 individuals from Lebanon, Saudi Arabia, Pakistan, and Syria diagnosed with CL by punch biopsy/scrapings were grouped into adults (>18 years) and pediatrics (≤18 years). Data recorded included clinical features [number, location, type, size, and extensiveness (size larger than 3 cm, more than 5 lesions per patient, lesion present for more than 12 months, special types, disfiguring lesion or closeness to vital sensory organs) of lesions] and microscopic findings [Ridley's Parasitic Index and Ridley's Pattern]. In addition, molecular confirmation and speciation were performed.

RESULTS

In comparison with adults, patients in the pediatric group (n = 158, 41.4%) showed significantly higher number of lesions, more facial involvement, and more extensive disease (P < .05). Microscopically, a more advanced Ridley's pattern was observed. The other variables did not show statistical difference between the two groups.

CONCLUSION

Historically, CL has been known to be a neglected tropical disease of poverty and pediatric predilection. In our pediatric group, CL manifests with more extensive disease clinically mirrored by more advanced lesions microscopically.

Molecular epidemiological survey of cutaneous leishmaniasis from Azad Jammu and Kashmir, Pakistan

Cutaneous leishmaniasis (CL) is an emerging neglected tropical disease in Azad Jammu and Kashmir which is an underdeveloped area. Prevalence and parasite species identification are the key factors to control disease in a particular population, which were the objectives of the present study. Due to a lack of previous data, we performed a district-based active CL surveillance in 2018. The data of CL, suspected (n = 20,000) cases were analyzed statistically and identified the parasite species in microscopic positive cases by ITS1-PCR RFLP and also obtained accession numbers MN891719-28 from gene Bank. The phylogenetic tree was constructed using MEGA6 software. Out of 20,000 CL, suspected cases the highest rate of 4.02% (135/3360) of CL in Mirpur and the lowest 1.58% (8/505) in Neelum was reported. The slide positivity rate, annual parasite incidence rate and annual blood examination rate were 2.27 per 1000 population, 0.08 and 0.34%. The males were more infected 58.12% (297/511) than females 41.88% (214/511) and the age group of 1-20 years were found highly infected 82.78% (423/511) than 21-40 years 13.89% (71/511) and 41-60 years 3.33% (17/511) in the studied population. The patients 56.36% (288/511) had a single lesion whereas 29.35% (150/511) had two, only 10.76% (31/288) and 8% (12/150) were using bed nets. The patients 14.29% (73/511) had three or more lesions were not using bed nets. Only 27.98% (143/511) patients had received treatment, while 72.02% (368/511) didn't. Microscopically positive cases were found to be 2.56% (511/20,000) and ITS1-PCR positive cases were found to be 91.39% (467/511). The RFLP assay confirmed the presence of Leishmania tropica in 467 samples.

[Pediatric cutaneous leishmaniasis in Morocco: Clinical and epidemiological features]

INTRODUCTION

Cutaneous leishmaniasis (CL) is a parasitic disease caused by a flagellate protozoa of the genus Leishmania and is a public health problem throughout the world. In Morocco, CL may be sporadic or endemic depending on the species of Leishmania and the region involved. Casablanca is a non-endemic city but many children with CL come from elsewhere in the country. The aim of our study is to describe the clinical and epidemiological particularities of CL diagnosed in children at the Casablanca University Hospital.

MATERIALS AND METHODS

A cross-sectional study was conducted between 2010 and 2016. All patients with one or more skin lesions suggestive of CL underwent parasitological and molecular investigation. Epidemiological and clinical data from patients with positive genotyping were collected and analyzed. A comparative study was made of epidemiological and clinical variables between children and adults and between different species found in children.

RESULTS

One hundred and six cases of CL were diagnosed, of which 40 in children (37.7%): 29 due to L. tropica (72.5%), 7 due to L. major (17.5%), and 4 due to L. infantum (10%). CL caused by L. tropica was significantly associated with children (P=0.009) and was distinguished by the predominance of the nodular form (P=0.04) and a facial location (P=0.007). Compared to adults, childhood CL lesions were characterized by their small size (P=0.001) and facial location (P=0.003). Children were treated mainly with pentavalent antimonials, with good safety and clinical response.

CONCLUSION

In our series, CL due to L. tropica was predominant in children, reflecting the epidemic nature and wide geographical distribution of this species in Morocco. CL due to L. tropica was significantly associated with facial location and nodular form in children.

Mucosal leishmaniasis: A forgotten disease, description and identification of species in 50 Colombian cases

INTRODUCTION

Mucosal leishmaniasis has a progressive course and can cause deformity and even mutilation in the affected areas. It is endemic in the American continent and it is mainly caused by Leishmania (Viannia) braziliensis.

OBJECTIVE

To describe a series of mucosal leishmaniasis cases and the infectious Leishmania species.

MATERIALS AND METHODS

We included 50 patients with a clinical diagnosis of mucosal leishmaniasis and parasitological confirmation, and we described their clinical and laboratory results. We performed species typing by PCR-RFLP using the miniexon sequence and hsp70 genes; confirmation was done by sequencing.

RESULTS

The median time of disease evolution was 2.9 years (range: 1 month to 16 years). The relevant clinical findings included mucosal infiltration (94%), cutaneous leishmaniasis scar (74%), total loss of the nasal septum (24%), nasal deformity (22%), and mucosal ulceration (38%). The symptoms reported included nasal obstruction (90%), epistaxis (72%), rhinorrhea (72%), dysphonia (28%), dysphagia (18%), and nasal pruritus (34%). The histopathological study revealed a pattern compatible with leishmaniasis in 86% of the biopsies, and amastigotes were identified in 14% of them. The Montenegro skin test was positive in 86% of patients, immunofluorescence in 84%, and culture in 8%. Leishmania (V.) braziliensis was identified in 88% of the samples, L. (V) panamensis in 8%, and L. (V.) guyanensis and L. (L.) amazonensis in 2% respectively.

CONCLUSION

In this study, we found a severe nasal disease with destruction and deformity of the nasal septum in 25% of the cases, probably associated with late diagnosis. Leishmania (V.) braziliensis was the predominant species. We described a case of mucosal leishmaniasis in Colombia caused by L. (L.) amazonensis for the first time.

Novel Loci Controlling Parasite Load in Organs of Mice Infected With Leishmania major, Their Interactions and Sex Influence

Leishmaniasis is a serious health problem in many countries, and continues expanding to new geographic areas including Europe and USA. This disease, caused by parasites of Leishmania spp. and transmitted by phlebotomine sand flies, causes up to 1.3 million new cases each year and despite efforts toward its functional dissection and treatment it causes 20–50 thousands deaths annually. Dependence of susceptibility to leishmaniasis on sex and host's genes was observed in humans and in mouse models. Several laboratories defined in mice a number of Lmr (Leishmania major response) genetic loci that control functional and pathological components of the response to and outcome of L. major infection. However, the development of its most aggressive form, visceral leishmaniasis, which is lethal if untreated, is not yet understood. Visceral leishmaniasis is caused by infection and inflammation of internal organs. Therefore, we analyzed the genetics of parasite load, spread to internal organs, and ensuing visceral pathology. Using a new PCR-based method of quantification of parasites in tissues we describe a network-like set of interacting genetic loci that control parasite load in different organs. Quantification of Leishmania parasites in lymph nodes, spleen and liver from infected F₂ hybrids between BALB/c and recombinant congenic strains CcS-9 and CcS-16 allowed us to map two novel parasite load controlling Leishmania major response loci, Lmr24 and Lmr27. We also detected parasite-controlling role of the previously described loci Lmr4, Lmr11, Lmr13, Lmr14, Lmr15, and Lmr25, and describe 8 genetic interactions between them. Lmr14, Lmr15, Lmr25, and Lmr27 controlled parasite load in liver and lymph nodes. In addition, Leishmania burden in lymph nodes but not liver was influenced by Lmr4 and Lmr24. In spleen, parasite load was controlled by Lmr11 and Lmr13. We detected a strong effect of sex on some of these genes. We also mapped additional genes controlling splenomegaly and hepatomegaly. This resulted in a systematized insight into genetic control of spread and load of Leishmania parasites and visceral pathology in the mammalian organism.

Spatial modeling of cutaneous leishmaniasis in Iranian army units during 2014-2017 using a hierarchical Bayesian method and the spatial scan statistic

OBJECTIVES

This study aimed to map the incidence of cutaneous leishmaniasis (CL) in Iranian army units (IAUs) and to identify possible spatial clusters.

METHODS

This ecological study investigated incident cases of CL between 2014 and 2017. CL data were extracted from the CL registry maintained by the deputy of health of AJA University of Medical Sciences. The standardized incidence ratio (SIR) of CL was computed with a Besag, York, and Mollié model. The purely spatial scan statistic was employed to detect the most likely highand low-rate clusters and to obtain the observed-to-expected (O/E) ratio for each detected cluster. The statistical significance of the clusters was assessed using the log likelihood ratio (LLR) test and Monte Carlo hypothesis testing.

RESULTS

A total of 1,144 new CL cases occurred in IAUs from 2014 to 2017, with an incidence rate of 260 per 100,000. Isfahan and Khuzestan Provinces were found to have more CL cases than expected in all studied years (SIR>1), while Kermanshah, Kerman, and Fars Provinces were observed to have been high-risk areas in only some years of the study period. The most significant CL cluster was in Kermanshah Province (O/E, 67.88; LLR, 1,200.62; p<0.001), followed by clusters in Isfahan Province (O/E, 6.02; LLR, 513.24; p<0.001) and Khuzestan Province (O/E, 2.35; LLR, 73.71; p<0.001), while low-rate clusters were located in the northeast areas, including Razavi Khorasan, North Khorasan, Semnan, and Golestan Provinces (O/E, 0.03; LLR, 95.11; p<0.001).

CONCLUSIONS

This study identified high-risk areas for CL. These findings have public health implications and should be considered when planning control interventions among IAUs.

Spatio-temporal analysis of cutaneous leishmaniasis using geographic information system among Iranian Army Units and its comparison with the general population of Iran during 2005-2014

To investigate the time trend and distribution of cutaneous leishmaniasis in Iranian Army Units (IAUs) and general population (GP). with using census, Data on CL incidence in IAUs (from AJA University of Medical Sciences) and GP (from Ministry of Health) during 2005-2014 were extracted and entered into the GIS software. Cochran-Armitage test, choropleth map, hot-spot analysis and high/low clustering analysis were used to determine time trend, distribution of disease, hot-spots, and possible abnormal clustering, respectively. The number of infected individuals in IAUs and GP were 6533 and 153,499 respectively (with incidence rates of 143.68 per 100,000 and 25.86 per 100,000, respectively). Time trend analysis revealed the departure from linear trend for the incidence in IAUs (p < 0.001), but no such time trend was found in GP. According to choropleth maps; in IAUs, Khozestan from southwest, Esfahan from central and Kermanshah from west parts of Iran and among GP; Fars, Yazd, and Kerman in southern-east of Iran showed a high incidence rates. In IAUs, Esfahan and Khuzestan provinces was hot-spots of CL (p < 0.05), but in GP, provinces like Fars and Khorasan-shomali was hot-spots (p < 0.05). No clustering pattern of disease was observed in either study populations. Observed spatiotemporal variability in CL among IAUs and GP warrants proper health programs particularly to Khozestan and Esfahan in IAUs and Fars and Khorasan-shomali in GP are highly recommended.

The PCR-RFLP-Based Detection and Identification of the Leishmania Species Causing Human Cutaneous Leishmaniasis in the Khorasan-Razavi Province, Northeast of Iran

BACKGROUND

Leishmania tropica, the causative agent of anthroponotic cutaneous leishmaniasis (ACL), and Leishmania major, which causes zoonotic cutaneous leishmaniasis (ZCL), are endemic in Iran.

METHODS

Cross-sectional study was designed to identify Leishmania species in cutaneous leishmaniasis patients who referred to Mashhad Health Centers from 2013 to 2014 using ITS-PCR-RFLP technique. First, physical examinations were performed in all suspected patients and CL cases were confirmed with microscopical examinations. A questionnaire was prepared and completed for each confirmed patient and DNA from each lesion smear was extracted, separately. The ribosomal internal transcribed spacer was amplified with appropriate primers and PCR products were digested by enzyme Taq1 restrict enzyme.

RESULTS

From all patients, 51 cases (54.3%) were men and 43 of them (45.7%) were women. The most frequent age group was 20-29 years old (27.2%). Hands, face and feet were the most common sites for appearance of skin lesions. All of the 94 cases (100%) tested found to be positive by ITS-PCR-RFLP. Overall, Leishmania species were identified in all of the 94 lesion smears which 33 (35%) of them were L. major and 61 (65%) of the remained isolates were identified L. tropica.

CONCLUSION

Characterization of Leishmania isolates collected from different parts of Khorasan-Razavi Province showed that L. tropica is predominant agents of CL, especially in large and medium sized cities such as Mashhad and Shandiz. Moreover, this study revealed that ITS-PCR-RFLP based on our designed primers is a suitable method for species characterization.

Sporotrichoid leishmaniasis: a cross-sectional clinical, epidemiological and laboratory study in Rio de Janeiro State, Brazil

Background

Atypical presentations of cutaneous leishmaniasis include sporotrichoid leishmaniasis (SL), which is clinically described as a primary ulcer combined with lymphangitis and nodules and/or ulcerated lesions along its pathway.

Aims

To assess the differences between patients with sporotrichoid leishmaniasis and typical cutaneous leishmaniasis (CL).

Methods

From January 2004 to December 2010, 23 cases of SL (4.7%) were detected among 494 CL patients diagnosed at a reference center for the disease in Rio de Janeiro State, Brazil. These 23 cases were compared with the remaining 471 patients presenting CL.

Results

SL predominated in female patients (60.9%, p = 0.024), with older age (p = 0.032) and with lesions in upper limbs (52.2%, p = 0.028). CL affected more men (64.5%), at younger age, and with a higher number of lesions exclusively in lower limbs (34.8%).

Conclusions

Differences in clinical and epidemiological presentation were found between SL patients as compared to CL ones, in a region with a known predominance of Leishmania (Viannia) braziliensis. The results are similar to the features of most of the sporotrichosis patients as described in literature, making the differential diagnosis between ATL and sporotrichosis more important in overlapping areas for both diseases, like in Rio de Janeiro State.

Incidence and Disability-Adjusted Life Years (Dalys) Attributable to Leishmaniasis In Iran, 2013

Background

Leishmaniasis covers a range of clinical manifestations. Estimation of the burden of leishmaniasis may help guide healthcare management personnel and policy-makers in applying effective interventions. The present study aimed to calculate the incidence and burden of cutaneous and visceral leishmaniasis in Iran in 2013.

Methods

To evaluate the epidemiological aspects of the disease in Iran, published studies over the past 20 years were searched and the viewpoints of relevant specialists in Iran were obtained. Data were collected from the Ministry of Health and from the Tehran University of Medical Sciences. To calculate years of life lost due to premature death, standard expected years of life lost was used. Standard life table of Global Burden of Disease (GBD) 2010 with the life expectancy of 86.02 years for both sexes was used to calculate the remaining potential years of life at any age from death.

Results

The overall incidence of cutaneous and visceral leishmaniasis was calculated as 22 and 0.092 per 100000 population of Iran, respectively. The burden of leishmaniasis was 99.5 years: 95.34 and 4.16 years for cutaneous and visceral, respectively. Sensitivity was analyzed and deaths predicted by the Institute of Health Metrics and Evaluation added, the burden of visceral leishmaniasis was 726 years.

Conclusion

The share of leishmaniasis burden in Iran is lower than the global burden of the disease. GBD 2010 standard method is recommended to calculate the burden of leishmaniasis in different countries and set local priorities on the basis of these measures.

Molecular Identification of Leishmania Species in a Re-Emerged Focus of Cutaneous Leishmaniasis in Varamin District, Iran

BACKGROUND

Cutaneous leishmaniasis (CL) is one of the most important neglected tropical diseases and a major public health challenge in Iran caused by Leishmania spp and transmitted by phlebotomine sand flies. The number of CL cases has shown an increasing pattern all over the country, including the district of Varamin, southeast of Tehran, Iran. This study aimed to identify the Leishmania spp isolated from CL patients using molecular methods in Varamin during 2012-2013.

METHODS

Exudate materials collected from the swollen edge of the skin lesions of 44 parasitological positive CL patients by disposable lancet. They were referred to Varamin Health Center by physician. The samples were subjected to molecular method for Leishmania species identification.

RESULTS

The digestion pattern of restriction enzyme revealed that 37 (84.1%) CL patients were infected with L. major and 7 (15.9%) were infected with L. tropica. They were mostly male than female. More than half of the patients (58%) had multiple lesions, and they were mostly observed on extremities, 34.1% on legs and 29.5% on hands. Lesions were mostly of wet ulcerative type.

CONCLUSION

Dominancy of L. major provides more evidence that Varamin District probably could be considered as Zoonotic Cutaneous Leishmaniasis (ZCL) areas. More investigation on other epidemiological aspects of disease is needed.

Spatial modeling of cutaneous leishmaniasis in Iran from 1983 to 2013

INTRODUCTION

Cutaneous Leshmaniasis (CL), a parasitic skin infection caused by Leishmania species, is endemic in some regions of Iran. In this study, the effect of location on the incidence and distribution of CL in Iran was studied.

METHODS

We collected datas including the number of Cutaneous Leishmaniasis cases and populations at-risk of disease in Iran's different provinces reported by the Iranian ministry of health and the National Bureau of Statistics, respectively. Spatial modeling was performed using Arc GIS software. Descriptive maps, hotspot analysis, and high/low clustering analysis were used to demonstrate distribution of the cutaneous leishmaniasis, to determine regions at risk of disease's incidence, and to reach the most appropriate method for clustering of disease.

RESULTS

The total number of cases of cutaneous leishmaniasis reported through the study period was 589,913. The annual incidence of CL was estimated to be 30.9 per 100,000 in Iranian population. We also demonstrated that Cutaneous leishmaniasis most prominently occurs in regions with dry and desert climates as well as in central parts of Iran. It affected the southwest of Iran between 1983 and 1997, and subsequently developed towards the center and the eastern between 1998 and 2013. Disease hotspots were focused in the provinces of Yazd, Khozestan and Kohgiloyeh-Boyer-Ahmad (p<0.05). No pattern of spatial clustering was observed.

CONCLUSION

Cutaneous leishmaniasis is a major health problem which could be a serious threat for inhabitants who live in high-risk provinces of Iran; much more resources need to be allocated in these areas, to warrant the prevention as well as effectively management of this disease.

Reprint of "Spatial modeling of Cutaneous Leishmaniasis in Iran from 1983 to 2013"

INTRODUCTION

Cutaneous Leshmaniasis (CL), a parasitic skin infection caused by Leishmania species, is endemic in some regions of Iran. In this study, the effect of location on the incidence and distribution of CL in Iran was studied.

METHODS

We collected datas including the number of Cutaneous Leishmaniasis cases and populations at-risk of disease in Iran's different provinces reported by the Iranian ministry of health and the National Bureau of Statistics, respectively. Spatial modeling was performed using Arc GIS software. Descriptive maps, hotspot analysis, and high/low clustering analysis were used to demonstrate distribution of the cutaneous leishmaniasis, to determine regions at risk of disease's incidence, and to reach the most appropriate method for clustering of disease.

RESULTS

The total number of cases of cutaneous leishmaniasis reported through the study period was 589,913. The annual incidence of CL was estimated to be 30.9 per 100,000 in Iranian population. We also demonstrated that Cutaneous leishmaniasis most prominently occurs in regions with dry and desert climates as well as in central parts of Iran. It affected the southwest of Iran between 1983 and 1997, and subsequently developed towards the center and the eastern between 1998 and 2013. Disease hotspots were focused in the provinces of Yazd, Khozestan and Kohgiloyeh-Boyer-Ahmad (p<0.05). No pattern of spatial clustering was observed.

CONCLUSION

Cutaneous leishmaniasis is a major health problem which could be a serious threat for inhabitants who live in high-risk provinces of Iran; much more resources need to be allocated in these areas, to warrant the prevention as well as effectively management of this disease.

Epidemiological trend of cutaneous leishmaniasis in two endemic focus of disease, south of Iran

Cutaneous leishmaniasis is one the most important zoonotic diseases has different invertebrate hosts in different parts of its range, the vectors are often closely related. Leishmaniasis is a world-wide vector borne disease, affecting 88 countries: especially in the Middle East and southwestern Asia. Nesokiaindica or M. libycuserythrourus are confirmed as reservoir and Phlebotomine sand flies are proven as vectors of the disease in the south of Iran. Patients' information collected from Firouzabad and Ghirokarzin county, Fars province in Iran during 2006-2014. Data analyzed by Chi square test using SPSS19 statistic software. 613 cases (61.91 %) lived in rural and 377 (38.08 %) lived in urban areas. All ages were grouped between 1 and ≥30 years. 479 (48.38 %) of patients being male and 511 (51.61 %) female. 39.49 % of patients were with dry lesions and 60.5 % were with wet lesions. Hand ulcers were the highest prevalence part of body (39.59 %). The common frequent size of lesions was lesser than 2 cm. Regarding the most prevalence rate (47.67 %) raised in autumn season. This study showed that cutaneous leishmaniasis was an endemic disease in Firouzabad and Ghirokarzin regions.

Pediatric Cutaneous Leishmaniasis in an Endemic Region in Turkey: A Retrospective Analysis of 8786 Cases during 1998-2014

BACKGROUND

Cutaneous leishmaniasis (CL) is a major public health concern in Turkey and Sanliurfa represents the most endemic city in Turkey. Although children are most commonly affected by CL, detailed studies of pediatric CL in Turkey are lacking.

METHODOLOGY/PRINCIPAL FINDINGS

In this report we retrospectively evaluated clinical and epidemiological data of 8786 pediatric CL cases, and how children respond to antimonial therapy. CL was observed most frequently in children between 6-10 years old. Interestingly this group showed shorter duration of disease and smaller lesions compared to 0-5 year and 11-15 year old groups. Females were more affected in all groups. Lesion localization and types varied among groups, with 0-5 year old presenting head/neck and mucosal lesions, and more often suffered from recidivans type, this could be associated to the longest duration of the disease in this group. Eleven-15 year old group showed fewer lesions in the head/neck but more generalized lesions. Evaluation of treatment response revealed that intra-lesional treatment was preferred over intramuscular treatment. However, 0-5 year old received intramuscular treatment more often than the other groups. Furthermore, the majority of 0-5 year old group which received intra-lesional treatment did not received subsequent intra-lesional cycles, as did children in the range of 6-15 years old.

CONCLUSIONS/SIGNIFICANCE

We report an increase in pediatric CL patients within the last four years. Analysis of pediatric CL patients by age revealed significant differences in CL progression. The data suggest that children between 0-5 years old responded better than other groups to intralesional treatment, since they received more often a single cycle of IL treatment, although follow up observation is required since they were more prone to develop recidivans. Eleven-15 year old patients comprise the largest percentage of patients receiving two or three cycles of intralesional treatment, suggesting that this group did not respond efficiently to intralesional treatment and highlighting the need for more effective therapeutic strategies against CL.

Leishmania major: Genetic Profiles of the Parasites Isolated from Chabahar, Southeastern Iran by PPIP-PCR

BACKGROUND

Leishmaniasis is important vector-borne parasitic disease worldwide, caused by the genus Leishmania. The objective of the current study was to identify genetic polymorphism in L. major, one of the species causing cutaneous leishmaniasis (CL), isolated from southeastern Iran, using Permissively Primed Intergenic Polymorphic-Polymerase Chain Reaction (PPIP-PCR) method.

METHODS

Overall, 340 patients with suspected CL were examined. They referred to the Central Laboratory in Chabahar, Iran during Apr 2013 to Feb 2014. Microscopic examination of Giemsa-stained slides from lesions as well as aspirates cultured in Novy- Mac Neal-Nicolle (NNN) Media was employed in order to diagnose CL in these patients. Our analyses detected 86 suspected subjects as having CL from which 35 isolates were cultured successfully. PPIP-PCR method was performed on extracted genomic DNA from selected isolates in order to determine the genetic polymorphism among L. major isolates.

RESULTS

The electrophoresis patterns demonstrated two genetic profiles including A or A1 patterns between all samples tested. Frequency of A and A1 sub-types were 33 (94.3%) and two (5.7%), respectively.

CONCLUSION

Both host and parasite factors may contribute to the clinical profile of human leishmaniasis in the endemic foci of the disease. Here we showed that genetic variations pertaining to the Leishmania parasites might determine, in part, the clinical outcomes of human leishmaniasis.

Species Identification and Molecular Typing of Leishmania Spp. Using Targeting HSP70 Gene in Suspected Patients of Cutaneous Leishmaniasis from Sistan and Baluchestan Province, Southeast Iran

BACKGROUND

Leishmaniasis is a sand fly-borne disease caused by the protozoan parasites belonging to the genus Leishmania. Because of the preventing and controlling methods, clinical course, prognosis and choice of treatment are differing from species; differentiation of species is critical. The present study was aimed to detect the parasite species using the PCR-RFLP method.

METHODS

A total of 130 Giemsa-Stained slides from suspected Cutaneous leishmaniasis (CL) patients were examined under a light microscope at ×1000. DNA from each slide was extracted PCR method was undertaken with HSP70 genes and the PCR products were digested with a restriction enzyme HaeIII (BsuR1). The study was conducted in the laboratory of Zahedan University of Medical Sciences in the Sistan and Baluchestan Province, southeastern Iran in 2015.

RESULTS

From 130 suspected samples, 59 (45.3%) were positive by the microscopic examination, meanwhile 64 (49.2%) were positive by PCR-RFLP, Leishmania species were recognized, and L. tropica was introduced as predominant species in current study.

CONCLUSION

PCR-RFLP is a valuable technique for distinguish of Leishmania species. Furthermore, anthroponotic CL is the dominant cause of CL in Sistan and Baluchestan Province.

Systemic Meglumine Antimoniate in Cutaneous Leishmaniasis of Children: Clinical and Laboratory Complications

Children account for 7%-20% of cutaneous leishmaniasis cases in Iran, but there are few safety data to guide pediatric antiparasitic therapy. We evaluated the clinical and laboratory tolerance of the systemic pentavalent antimonial compound meglumine antimoniate, in 70 Iranian children with cutaneous leishmaniasis. Adverse effects were similar to those seen in adults.

Metabolomics-Based Study of Logarithmic and Stationary Phases of Promastigotes in Leishmania major by 1H NMR Spectroscopy

Background:

Cutaneous leishmaniasis is one of the most important parasitic diseases in humans. In this disease, one of the responsible organisms is Leishmania major, which is transmitted by sandfly vector. There are specific differences in biochemical profiles and metabolite pathways in logarithmic and stationary phases of Leishmania parasites. In the present study, ¹H NMR spectroscopy was used to examine the metabolites outliers in the logarithmic and stationary phases of promastigotes in L. major to enlighten more about the transmission mechanism in metacyclogenesis of L. major.

Methods:

Promastigote was cultured, logarithmic and stationary phases were separated by the peanut agglutinin, and cell metabolites were extracted. ¹H NMR spectroscopy was applied, and outliers were analyzed using principal component analysis.

Results:

The most altered metabolites in stationary and logarithmic phases were limited to citraconic acid, isopropylmalic acid, L-leucine, ornithine, caprylic acid, capric acid, and acetic acid.

Conclusion:

¹H NMR spectroscopy could play an important role in the characterization of metabolites in biochemical pathways during a metacyclogenesis process. These metabolites and their pathways can help in exploiting a transmission mechanism in metacyclogenesis, and outcoming data might be used in the metabolic network reconstruction of L. major modeling.

Trend of cutaneous leishmaniasis in kermanshah province, west of iran from 1990 to 2012

BACKGROUND

This study was conducted to explain the trend of Cutaneous Leishmaniasis (CL) in Kermanshah Province, western Iran from 1991-2012.

METHODS

In this analytical-descriptive study, all of the patients suspected to CL in Kermanshah Province were studied. Smears were prepared from most of them, stained with Giemsa, and examined microscopically for Leishman bodies. A few of the patients were diagnosed according to physician diagnosis and response to glucantime. Questionnaires were completed for all of them. Collected data were analyzed using SPSS-21 and Spearman and Kendall tests.

RESULTS

From 1991 to 2012, 1684 cases of CL were recorded. In the years 2011-12 the frequency of CL in the province reached to 7.4/100,000, which showed a remarkable increase in the frequency of new cases CL in the province. In the years 2011-12 about 47% of total cases of CL in the province, was seen in Ghasr-e-Shirin district,which the frequency of CL in this district reached to 264.5/100,000. Frequency of CL in males and females was 57% and 43% respectively. The most cases of CL were seen in housewives (32.1%) and age groups of 20 to 29 years old (19.9%). In addition, the most cases of disease were seen in winter (41.8%) and fall (28.9%).

CONCLUSION

CL is increasing remarkably in warm climates of the province, and Ghasr-e-Shirin must be of particular interest, as the most infected district in the province.

Pediatric cutaneous leishmaniasis in an endemic region in India

Cutaneous leishmaniasis (CL) is endemic in the Bikaner region situated in the Thar Desert of Rajasthan, India. This study describes clinicoepidemiological data of pediatric CL in pre-school children (0-5 years of age) from this region during 2001-2012. In total, 151 patients with 217 lesions were reported during the study period. The mean age of the study group was 3.29 ± 1.43 years (0.25-5 years), with many (41.7%) cases being in the age group of 2-4 years. Face was the most common site involved, and morphologically, the lesions were either plaque type or papulonodular. Smear for parasitologic examination was positive in 84 (70%) of 120 cases, and histopathologic examination confirmed CL in 10 (55.55%) of 18 cases. Parasite species identification conducted for 13 randomly selected patients by polymerase chain reaction identified Leishmania tropica as the causative species. Intralesional sodium stibogluconate was the most commonly used treatment and found to be well-tolerated. Other therapies that were effective included oral rifampicin, oral dapsone, radiofrequency heat therapy (RFHT), and combinations of the three therapies.

Domestic and peridomestic risk factors associated with transmission of cutaneous leishmaniasis in three hypo endemic, endemic, and hyper endemic areas: A randomized epidemiological study

BACKGROUND

Leishmaniasis is an infection caused by leishmania protozoa. Knowledge about health effects associated with environment situation and human behavior in national and local levels seems to be very necessary.

MATERIALS AND METHODS

This cross-sectional case-control study was carried out in three adjacent counties of Isfahan province in Iran. Data were collected by face-to-face interviewing and recorded structured questionnaire. Statistical analysis was performed using Chi-square test and logistic. P < 0.05 was considered as significant.

RESULTS

The economic level had significant association with cutaneous leishmaniasis (CL) transmission (P < 0.05). However, there was no significant association between existence of food storage and transmission of CL. We, however, found significant reduction of CL transmission following use of insect control measures (P < 0.05). The odds ratio for peridomestic transmission was 0.420 for houses that weren't round with any old or ruined houses.

CONCLUSION

We conclude that among aforementioned risk factors, the impact of peridomestic factors is stronger in CL transmission when compared with domestic and behavioral factors.

Knowledge, attitude, and practices related to cutaneous leishmaniasis in an endemic focus of cutaneous leishmaniasis, Southern Iran

OBJECTIVE

To assess knowledge, attitudes, and practices (KAP) of inhabitants of an endemic area in Fars province toward cutaneous leishmaniasis (CL).

METHODS

The study was carried out in Lapui district in Fars province, south of Iran, one of the most important foci of CL in this province. Sample size (237 residents) was calculated based on population. House-to-house survey was done to collect the data regarding knowledge, attitudes, and practices of the inhabitants. The head of each household was interviewed by a trained staff to assess his/her KAP related to CL. A semi-structured KAP questionnaire was used for data collection.

RESULTS

Mean age of participants was 39 and more than half of the respondents were in the age group of 31-40. Males constituted 172 (72.5%) of subjects. Most of the respondents (84.3%) were literate. The majority of the study population (83%) had heard about Salak (local name for CL) and most of these respondents (91%) were aware that CL is presented with a cutaneous lesion. Nearly two-third of the participants (63.5%) stated the bite of mosquito (not specifically sandflies) for CL transmission. The respondents' attitude regarding the treatment of CL was not satisfactory since only 48% believed that CL can be treated by medicine. A noticeable proportion of respondents (21%) believed in indigenous medicine for the treatment of CL. A small proportion of respondents (14%) stated that traditional healers are good at treating this disease. More than two-third (69%) of respondents believed that the disease is preventable although most of interviewees did not know about preventive measures.

CONCLUSIONS

In this study, insufficient knowledge of community about infection nature, vector, transmission mode and preventive measures of CL, highlights the needs for a health education initiative to enhance the awareness of people about CL. This would improve inhabitants' contribution in control program of CL in this area.

Geographic information system-based analysis of the spatial and spatio-temporal distribution of zoonotic cutaneous leishmaniasis in Golestan Province, north-east of Iran

Zoonotic cutaneous leishmaniasis (ZCL), a vector-borne disease, poses serious psychological as well as social and economic burden to many rural areas of Iran. The main objectives of this study were to analyse yearly spatial distribution and the possible spatial and spatio-temporal clusters of the disease to better understand spatio-temporal epidemiological aspects of ZCL in rural areas of an endemic province, located in north-east of Iran. Cross-sectional survey was performed on 2983 recorded cases during the period of 2010-2012 at village level throughout the study area. Global clustering methods including the average nearest-neighbour distance, Moran's I, general G indices and Ripley's K-function were applied to investigate the annual spatial distribution of the existing point patterns. Presence of spatial and spatio-temporal clusters was investigated using the spatial and space-time scan statistics. For each year, semivariogram analysis and all global clustering methods indicated meaningful persistent spatial autocorrelation and highly clustered distribution of ZCL, respectively. Eight significant spatial clusters, mainly located in north and northeast of the province, and one space-time cluster, observed in northern part of the province and during the period of September 2010-November 2010, were detected. Comparison of the location of ZCL clusters with environmental conditions of the study area showed that 97.8% of cases in clusters were located at low altitudes below 725 m above sea level with predominantly arid and semi-arid climates and poor socio-economic conditions. The identified clusters highlight high-risk areas requiring special plans and resources for more close monitoring and control of the disease.

A newly emerged cutaneous leishmaniasis focus in central Iran

OBJECTIVES

This study was performed to evaluate the epidemiological status of cutaneous leishmaniasis (CL) in the most important endemic foci of Qom Province, central Iran. The city of Qom is the largest center for Shi'a scholarship in the world and is a significant pilgrimage destination.

METHODS

During 2006-2011, all suspected CL patients with skin lesion(s) referred to regional health centers of Ghomrood and Ghanavat regions, and all actively detected cases, were examined clinically and parasitologically for CL. Patient information was recorded and patients were categorized based on the number and size of the lesions. Odds ratios (OR) of different risk factors were calculated.

RESULTS

A total of 849 (59.2% male, 40.8% female) confirmed cases of CL were enrolled; the average incidence rate of the disease was 14.9 per 100000 people. During the study period 2006-2011, the trend in CL incidence showed no sudden variations in the areas studied, except for an outbreak of CL in 2009. Leishmania major was identified as the causative agent based on internal transcribed spacer 1 (ITS1) ribosomal DNA PCR analysis. During the study period, the age distribution of CL cases was relatively stable, with the majority (50%) of patients aged 1-25 years. Most cases (n=468; 55.1%) had a single lesion and 82 (9.6%) patients had four or more lesions (range 1-29). The risk of developing multiple lesions was significantly increased in patients with seasonal jobs (summer workers) (p=0.023; OR 1.516) and significantly decreased in patients who were affected in winter (p=0.010; OR 0.398). The risk of developing large-sized lesions (>1cm) was significantly increased in patients in the age groups>25 years (p=0.001-0.015; OR 2.5-3.5) and decreased in patients with seasonal jobs (summer workers) (p=0.005; OR 0.570).

CONCLUSIONS

The present data show the importance of CL as a health problem in suburban areas of Qom Province. In order to identify other epidemiological aspects of leishmaniasis in this area, studies on vectors and reservoirs are recommended. Since leishmaniasis caused by L. major is typically zoonotic, control measures should focus on rodents as the main reservoirs and Phlebotomus papatasi as the main vector. Awareness should be raised in the high-risk populations comprising people with diabetes, young adults (<25 years old), and those who work outdoors during the summer.

Overexpression of ubiquitin and amino acid permease genes in association with antimony resistance in Leishmania tropica field isolates

The mainstay therapy against leishmaniasis is still pentavalent antimonial drugs; however, the rate of antimony resistance is increasing in endemic regions such as Iran. Understanding the molecular basis of resistance to antimonials could be helpful to improve treatment strategies. This study aimed to recognize genes involved in antimony resistance of Leishmania tropica field isolates. Sensitive and resistant L. tropica parasites were isolated from anthroponotic cutaneous leishmaniasis patients and drug susceptibility of parasites to meglumine antimoniate (Glucantime®) was confirmed using in vitro assay. Then, complementary DNA-amplified fragment length polymorphism (cDNA-AFLP) and real-time reverse transcriptase-PCR (RT-PCR) approaches were utilized on mRNAs from resistant and sensitive L. tropica isolates. We identified 2 known genes, ubiquitin implicated in protein degradation and amino acid permease (AAP3) involved in arginine uptake. Also, we identified 1 gene encoding hypothetical protein. Real-time RT-PCR revealed a significant upregulation of ubiquitin (2.54-fold), and AAP3 (2.86-fold) (P<0.05) in a resistant isolate compared to a sensitive one. Our results suggest that overexpression of ubiquitin and AAP3 could potentially implicated in natural antimony resistance.

Spatial analysis of eco-environmental risk factors of cutaneous leishmaniasis in Southern Iran

Background:

Despite the advances in the diagnosis and treatment of leishmaniasis, it is still considered as a severe public health problem particularly in developing countries and a great economic burden on the health resources. The present study was designed and conducted to determine the eco-environmental characteristics of the leishmaniasis disease by spatial analysis.

Materials and Methods:

In an ecological study, data were collected on eco-environmental factors of Fars province in Iran and on cutaneous leishmaniasis (CL) cases from 2002 to 2009. geographic weighted regression (GWR) was used to analyse the data and compare them with ordinary least square (OLS) regression model results. Moran's Index was applied for analysis of spatial autocorrelation in residual of OLS. P value less than 0.05 was considered as significant and adjusted R² was used for model preferences.

Results:

There was a significant spatial autocorrelation in the residuals of OLS model (Z=2.45, P=0.014). GWR showed that rainy days, minimum temperature, wind velocity, maximum relative humidity and population density were the most important eco-environmental risk factors and explained 0.388 of the associated factors of CL.

Conclusion:

Spatial analysis can be a good tool for detection and prediction of CL disease. In autocorrelated and non-stationary data, GWR model yields a better fitness than OLS regression model. Also, population density can be used as a surrogate variable of acquired immunity and increase the adjusted R².

Systemic meglumine antimoniate in acute cutaneous leishmaniasis: children versus adults

Some studies showed that children have a lower response to systemic use of pentavalent antimoniate than adults. We aimed to evaluate the response rate to Glucantime therapy in children and compare it with adults. One hundred and twelve patients with acute cutaneous leishmaniasis: (ACL) were divided into two equal groups of adults (> 15 yrs) and children (≤ 15 yrs). They received meglumine antimoniate; 20 mg/kg/day for 20 days, their improvement rate was evaluated 20 and 45 days after treatment. Per-protocol analysis showed a significantly lower response in the children group 20 and 45 days after initiation of the treatment (P = 0.0001, 95% confidence interval [CI] = 0.190 [0.079-0.456]/P = 0.0051, 95% CI = 0.317 [0.140-0.717], respectively). Moreover, after intention-to-treat analysis, the same results were seen in the younger group 20 and 45 days after treatment (P = 0.0003, 95% CI = 0.228 [0.098-0.528]/P = 0.0132, 95% CI = 0.382 [0.177-0.825], respectively). According to our results, systemic Glucantime has lower efficacy in treating ACL in children than adults.

The changing profile of cutaneous leishmaniasis in a focus of the disease in Jahrom district, southern Iran

Human cutaneous leishmaniasis (CL) is endemic in several parts of Iran, and there is an urban focus of the disease in the district of Jahrom, which forms part of the southern province of Fars. To explore the current profile of the disease in Jahrom district, samples were taken from the skin lesions of 40 cases of CL patients in the district, so that the causative parasites could be identified, to species, in a nested PCR. Although Leishmania tropica has been identified, in the past, as the cause of most of the urban CL in Fars province, the predominant species represented in the recent samples from Jahrom district was L. major (87.5%), while L. tropica was relatively rare (12.5%). More than one in every three (35%) of the cases examined was a child aged <10 years. The most common location of the skin lesions was on the hands. Although most of the cases had one skin lesion each, two cases each had >25 such lesions. The change in the predominant parasite causing CL in Jahrom district, from the L. tropica usually associated with the urban disease in Iran to the L. major more usually associated with CL in rural settings, may well necessitate changes in the local strategies for the prevention and control of CL.

Identification of Leishmania parasites in clinical samples obtained from cutaneous leishmaniasis patients using PCR-RFLP technique in endemic region, Sanliurfa province, in Turkey

Antroponotic cutaneous leishmaniasis (ACL) is an endemic disease and one of the major health problems in Sanliurfa province located in the southeastern region of Turkey. Leishmania tropica is confirmed as the causative agent of ACL in this region. In Sanliurfa city alone, the recorded total cases of ACL were 6,817 between 2001 and 2006. We aimed to determine the effectiveness of a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method for identification and differentiation of the Leishmania parasite in comparison to direct microscopic examination of clinical samples. The lesion exudates were collected from 51 ACL suspected patients and used for smear-slide preparations and DNA isolation. The isolated DNA was amplified by PCR, including primers selected on repetitive DNA for identification of a Leishmania subgenus, and the amplified DNA was restricted by HaeIII restriction endonuclease. The PCR-RFLP results showed that only L. tropica exists in this province. It is also determined that the positivity rate with PCR was higher (96%) than by microscopic examination (64%) in the diagnosis of ACL. Our results indicate that the PCR-RFLP method is more sensitive and specific for the detection and differentiation of agents of ACL in this area.

Atypical presentation of Old-World cutaneous leishmaniasis, diagnosis and species identification by PCR

BACKGROUND

The diagnosis of cutaneous leishmaniasis (CL) is traditionally based on microscopic demonstration of amastigote forms in tissue biopsies or smears. However, this method usually presents low sensitivity, and in atypical forms, CL may be overlooked because of similarity to other dermal diseases. Thus, it is necessary to apply specific diagnostic methods as polymerase chain reaction (PCR).

OBJECTIVE

To evaluate the possible advantage of PCR in the diagnosis and species identification of CL in patients with atypical clinical presentation.

METHODS

Fifty-one patients clinically suspected of CL with positive and negative controls were tested. After microscopic examination, extraction of DNA was performed on their smears and analysed by two specific PCR assays for diagnosis and species identification. For these methods, conserved and variable regions of kinetoplastic DNA (KDNA) of Leishmania species have been amplified, respectively. Atypical forms of CL were evaluated among PCR-positive patients.

RESULTS

PCR results were positive in 37 out of 51 cases (72.5%), among whom microscopic examination revealed Leishmania amastigotes in only 3 (5.9%). Among these patients, 10 (27%) had atypical presentation of CL; using species-specific primers, 6 patients had Leishmania major, 3 had Leishmania tropica and 1 patient had no species diagnosis. None of the samples of other dermal diseases revealed positive results (specificity, 100%). All patients were successfully treated by CL-specific drug regimens.

DISCUSSION

The results showed that KDNA PCR methods have a higher sensitivity compared with microscopic method. Moreover, PCR could identify the parasite species for specific therapy. Microscopic method had low sensitivity and less value in chronic and atypical CL cases.