Cutaneous leishmaniasis due to

Leishmania aethiopicaClinical presentations & complications

Mesfin Hunegnaw, MD

July 2011, Addis Ababa

Leishmania aethiopica

• It is the dominant species causing Cutaneous

leishmaniasis (CL) in Ethiopia

• Clinical subtypes:

- Localized CL

- Mucocutaneous

- Diffuse

Localized cutaneous leishmaniasis

Incubation period variable, usually several weeks

Infection may be subclinical or clinical

Subclinical cases may manifest with immunosuppression

Primary lesion may be patch of erythematous induration at

site of sandfly bite

Progresses to papulonodular, plaque or ulcerative lesion

Localized cutaneous leishmaniasis

When it ulcerates it forms central depression and

raised indurated border

Nodules plaques or ulcers may enlarge to assume a

diameter of several centimeters

May persist for months or years before eventually

healing with an atrophic scar

Many lesions do not ulcerate but persist as nodules or

plaques

Localized cutaneous leishmaniasis

Some patients have more than one primary lesion

Lesions are not always well-defined

Because of lymphatic spread, may get:

Satellite lesions

Sporotichoid spread

Local lymphangitis

Local lymphadenopathy

2 large lesions, both poorly defined. Only showed partial response to parenteral antimonial at end of 2nd cycle

Inadequate treatment resulting in leishmaniasis recidivans: This will now be difficult to treat

HIV co-infection

• As large as 5.6% co-infection rate (report from Tigray)

• Clinical presentations are

– Atypical

– Severe

– ↑ risk diffuse & mucocutaneous involvement

– Poor responses to standard therapy

– Higher relapse rate

Diffuse cutaneous leishmaniasis

• L. aethiopica

• Initial lesion may be small and well-defined

• Then multiple nodular & infiltrative lesions may appear

• Resembles lepromatous leprosy

• Lesions occasionally ulcerate and scar causing deformity

• Diffuse CL may appear months/years after initial lesion healed

• Poor CMI: Lesions are laden with parasite

• Poor treatment responses & high relapse rate

Diffuse CL very disfiguring and treatment unresponsive

Ulcerative DCL

Ulceration, Contracture and deformity of the fingers

Extensive scaring, deformity & contractures

Mucocutaneous leishmaniasis

• Causative agent is L. aethiopica• Occurs from lymphatic spread of amastigote • Mucosal infection can occur in the presence or absence of

the primary • Primary lesion may be adjacent to nostril or anywhere on

the face• Often significant facial lymphodema because of rich facial

lymphatic supply• The early symptoms of mucosal infection:

• nasal congestion • epistaxis

Mucosal spread with lesions Naso-pharinigeal area

Spread of facial lesion to lower lip mucosa with oedema

Mucosal spread with severe facial lymphoedema developed one year after scar healed

Scarring from previous lesions. Patient now complains of nasal stuffiness & epistaxis

Untreated facial lesion self-healed. Patient now has mucosal disease affecting lips

Although lesion is defined patient is c/o of nasal congestion

Mucocutaneous leishmaniasis

• Lesions can be destructive: nasal septum & other cartilaginous

structures

• How great is the risk of inadequately treated CL progressing to

mucosal disease? Difficult to assess:

- Because of severe stigma, patients are isolated in home & villages and

do not seek treatment

- May be due to culture, the patients do not return to same clinician

when there is disease recurrence. They seek treatment elsewhere

HIV -ve. Lesions still very active. c/o epistaxis

HIV positive. Palate also affected

HIV -ve. Previously healed facial lesions with scarring. Active mucosal disease

Also has active lesions over hands associated with severe scarring and deformity

Goals of therapy

• Accelerate healing• Minimize scarring• Prevent complications• Prevent disease progression• Decrease risk of relapse

Antimonials

• Have efficacy against L. aethiopica

• Localized lesions respond well

• Established MCL or diffuse leish respond poorly

• Aim of treatment should be;

- Clinical & parasitological cure

- To prevent any risk of disease progressing to MCL or diffuse

leishmaniasis as cure will be difficult/ impossible

Summary

• L. aethiopica is not a benign species

• Severe disease is probably underestimated as stigma might

cause social isolation

• We have seen cases of facial lesions which have

‘metastasized’ to mucosa

• Significantly associated lymphodema suggests lymphatic

spread

• DCL may manifest many years after single lesion has healed