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Mucocutaneous Leishmaniasis

Leishmaniasis Mucocutaneous American

Leishmaniasis is a parasitic infection that is endemic in some areas of Latin America, the Middle East, North Africa, and the Mediterranean. Mucocutaneous leishmaniasis is one of the three main clinical types of the disease. Biopsy of the lesion or a swab should be obtained for microbiological testing in order to confirm the diagnosis.


Presentation

With approximately 1.3 million infections and more than 50,000 deaths every year, leishmaniasis is an important infectious disease that has an endemic status in the majority of Latin America, countries of the Mediterranean basin, the Middle East, and certain areas of Africa and Asia [1] [2] [3] [4] [5] [6]. The protozoan parasite Leishmania, the causative agent of leishmaniasis, is transmitted to the human host by the sand fly vector from a number of animal hosts (or other human hosts that are already infected, in which case the term anthroponotic leishmaniasis is used) [1] [3]. Mucocutaneous leishmaniasis is one of the three clinical forms (in addition to visceral and cutaneous) of this parasitic infection, distinguished by the onset of lesions on the skin and on mucous membranes as well [1] [2] [3] [4] [7] [8]. Certain Leishmania species (L. braziliensis, L. major, L. panamensis, L. guyanensis, L. infantum, and L. donovani) are known for their propensity to produce mucocutaneous forms that start with the development of an erythematous papule at the site of the sand fly bite [1] [3]. The face and the extremities are usually the locations of the initial lesion, which can appear weeks or even years after the bite [1] [3]. Over time, the papule increases in size and eventually breaks, leading to the formation of a painless, well-demarcated ulcer [1] [3]. Spontaneous resolution within a few months is seen in the majority of cases, but new lesions might appear at various sites on the body [1] [3]. The distinguishing feature of mucocutaneous leishmaniasis is the mucosal involvement, predominantly in the oral cavity and the nasopharynx [2] [8].

Fever
  • The main side effects were headache and fever (7 cases), together with leucopenia and eosinophilia (4 cases).[ncbi.nlm.nih.gov]
  • There may be fever, chills, malaise, cough, anorexia, anemia, and wasting. The Leishmania organisms multiply in the cells of the reticuloendothelial system, eventually causing hyperplasia of the cells, especially those of the liver and spleen.[medical-dictionary.thefreedictionary.com]
  • [Dunglison1855] The Low Fever Typhus Mitior in Latin. [Hooper1822] Low Continued Fever Typhoid Fever, Febricula, Little Fever. [Symptom, Nature, etc. of the Febricula or Little Fever, Manningham, 1746].[antiquusmorbus.com]
  • He noted that he had visited Costa Rica in early 1996 and that he developed an intermittent fever similar to that of influenza (38 to 38.5[degrees] C) 3 weeks after he had returned to Italy.[the-medical-dictionary.com]
  • Symptoms include fever (often 2 fever spikes per day), enlargement of the spleen and liver, weakness, and progressive emaciation. The disease is often fatal without treatment, but survivors often develop immunity.[msu.edu]
Generalized Lymphadenopathy
  • . • Infection and multiplication in cells of the monocyte/macrophage line leads to generalized lymphadenopathy and splenomegaly. • Immune complex formation contributes to the pathological changes. • Visceral leishmaniasis is a chronic wasting disease[leishmaniasis.info]
  • Other manifestations may include generalized lymphadenopathy; hyperpigmented skin of the forehead, abdomen, hands, and feet in light-skinned persons; skin lesions in dark-skinned persons; signs of bleeding (petechiae, epistaxis, bleeding gums); jaundice[wynman.com]
Nasal Ulcer
  • A 55-year-old man presented with a nasal ulcer of four years' duration. He had been treated for borderline lepromatous (BL) leprosy 25 years earlier. Differential diagnoses of MCL, lupus vulgaris, and subcutaneous mycosis were considered.[ncbi.nlm.nih.gov]
Nasal Congestion
  • A 35-year-old man with nasal congestion, swelling, and pain. N Engl J Med 2005;352:609-15. 3. Vera LA, Macedo JL, Ciuffo IA, Santos CG, Santos JB.[ijdvl.com]
Palpitations
  • Treatment with liposomal amphotericin B was started but was soon terminated because of palpitation, epigastralgia and facial flushing.[ncbi.nlm.nih.gov]
Lacrimation
  • PURPOSE: This study describes lacrimal tract involvement and surgical outcome in patients with mucocutaneous leishmaniasis.[ncbi.nlm.nih.gov]
Skin Lesion
  • The helper/suppressor (H/S) ratio in the skin lesions was 1.6 /- 0.5 and in the nasal lesions of mucosal leishmaniasis was 1.7 /- 0.8.[ncbi.nlm.nih.gov]
  • A Leishmania species was recovered in culture from the buffy coat of peripheral blood of a patient who had American mucocutaneous leishmaniasis, although cultures of biopsy material from the skin lesions were unsuccessful.[ncbi.nlm.nih.gov]
  • We report here 2 patients with unusual presentations of diffuse cutaneous leishmaniasis presenting with large hypopigmented skin lesions mimicking borderline-tuberculoid leprosy.[ncbi.nlm.nih.gov]
  • The treatment measures include: Oral medicines and topical ointments/applications for skin lesions: The ulcers do not go away on their own without suitable treatment If the ulcers heal and cause cosmetic disfigurement, then plastic surgery may be performed[dovemed.com]
  • One year later, physical examination revealed that the patient experienced a marked improvement and the skin lesions had almost disappeared.[the-medical-dictionary.com]
Skin Ulcer
  • Four patients presented with large skin ulcers, and 9 had mucosal involvement as the main manifestation, the latter affecting the nose (3 cases), nose and septum (2 cases), nose and oral cavity (1 case), and nose, pharynx and larynx (3 cases).[ncbi.nlm.nih.gov]
  • Whether through medical treatment or through spontaneous resolution, skin ulcerations generally result in disfiguring scars with significant social and economic impact.[ncbi.nlm.nih.gov]
  • Cutaneous leishmaniasis (CL) can produce large numbers of skin ulcers—as many as 200 in some cases—on the exposed parts of the body, such as the face, arms and legs, causing serious disability and leaving the patient permanently scarred.[the-travel-doctor.com]
  • Mucocutaneous leishmaniasis A rare form of the disease, mucocutaneous leishmaniasis is caused by the cutaneous form of the parasite and can occur several months after skin ulcers heal.[healthline.com]
  • Cutaneous leishmaniasis causes skin ulcers; mucocutaneous leishmaniasis causes destructive lesions of the mucous membranes of the nose, mouth, and throat; visceral leishmaniasis is the most severe form of the disease and is manifested with anemia, weight[fpnotebook.com]
Cutaneous Manifestation
  • Yet the infrequency of mucocutaneous disease compared with cutaneous manifestations, and the difficulty of isolating parasites from mucocutaneous lesions have restricted the study of the organisms involved.[ajtmh.org]
  • Therefore, these lesions can be confused with those found in Wegener's granulomatosis (which is also marked by cutaneous manifestations and can involve the nasal mucosa), leprosy, and tuberculosis. (9) Cultures and recombinant immunoenzymatic testing[the-medical-dictionary.com]
  • A range of cutaneous manifestations occurs due to Leishmania infection. The species of parasite is the most important determinant of clinical outcome.[mdpi.com]
  • manifestations can be further subdivided into localized, diffuse (disseminated), recidivans, and post–kala-azar dermal leishmaniasis Geographic occurrence: Old World leishmaniasis is caused by Leishmania species found in Africa, Asia, the Middle East[emedicine.medscape.com]
Tropical Ulcer
  • Differential Diagnosis: Numerous primary and secondary skin diseases/conditions such as other tropical ulcers, impetigo, infected insect bites, leprosy, lupus vulgaris, tertiary syphilis, yaws, blastomycosis, skin cancer, and others.[wynman.com]
Flushing
  • Treatment with liposomal amphotericin B was started but was soon terminated because of palpitation, epigastralgia and facial flushing.[ncbi.nlm.nih.gov]

Workup

A thorough clinical approach is necessary in order to make the diagnosis of mucocutaneous leishmaniasis. A meticulously obtained patient history should be the first step, during which the physician must bear in mind the country of residence and travel to endemic areas in the past several years, whereas a history of sand fly bites might be assessed as well. A properly conducted physical examination, with an emphasis on the inspection of the skin and the oral cavity, may be even more important for identifying the lesions seen in mucocutaneous leishmaniasis. To solidify clinical suspicion, however, several microbiological tests can be employed. Scrapings from the lesions are used for microscopic smear examination or cultivation, the former being a superior method due to the longer turnaround time of cultures (up to 10 days are necessary for Leishmania to grow on standard media) [3] [4]. A histological examination of a biopsy sample (using hematoxylin-eosin staining) can be carried out, but the introduction of serological and molecular studies have greatly improved the overall rate of diagnosis [3] [4]. The Montenegro's test, comprised of inoculating Leishmania antigen into the forearm, can yield conclusive results after 72 hours [3] [4] [8]. Polymerase chain reaction (PCR), although being expensive and more sophisticated compared to the previously mentioned methods, should be implemented whenever possible, primarily because of its very high sensitivity/specificity rates [3] [4] [9].

Trichophyton Mentagrophytes
  • mentagrophytes var interdigitale isolated in a university hospital in Japan based on the nontranscribed spacer regi...[books.google.de]
Leishmania in Tissue
  • Detection and characterization of leishmania in tissues of patients with post kala-azar dermal leishmaniasis using a specific monoclonal antibody. Trans. R. Soc. Trop. Med.[mdpi.com]

Treatment

  • CONCLUSION: Prolonged and high-dose treatment regimens with itraconazole are not effective for the treatment of the majority of patients with MCL.[ncbi.nlm.nih.gov]
  • Current treatments of CL are poorly justified and have sub-optimal effectiveness. Treatment can be based on topical or systemic regimens. These different options must be based on Leishmania species, geographic regions, and clinical presentations.[ncbi.nlm.nih.gov]
  • ) or 12 (mucosal cases) months after the end of treatment.[ncbi.nlm.nih.gov]
  • A clinical pilot study was conducted to analyze itraconazole as an oral alternative for the treatment of mucocutaneous leishmaniasis.[ncbi.nlm.nih.gov]
  • After receiving anti-leishmanial treatment, the individual's specific Th1 immune response was restored.[ncbi.nlm.nih.gov]

Prognosis

  • The authors concluded that histopathological patterns do not represent a stage of tegumentary leishmaniasis, thus they can not be correlated with prognosis and therapeutical response as suggested in the literature.[ncbi.nlm.nih.gov]
  • When it was acute the onset was usually rapid, and though it resulted in much tissue destruction the prognosis was generally better and mucosal metastasis rare.[ncbi.nlm.nih.gov]
  • CONCLUSION: A classification or staging system enhances the ability to evaluate patients with mucocutaneous leishmaniasis and determine more accurately their prognosis and treatment.[ncbi.nlm.nih.gov]
  • Restorative surgery may be required for severe cases The prognosis depends upon the promptness in providing appropriate treatment.[dovemed.com]
  • Clinical observations, with special reference to factors influencing prognosis, Rev. Infect.[books.google.de]

Etiology

  • Midline destructive lesions have multiple possible etiologies, which can be grouped into neoplastic, infectious, or vasculitis-associated.[ncbi.nlm.nih.gov]
  • OBJECTIVE: Mucocutaneous leishmaniasis is widely distributed in Brazil, with Leishmania (Viannia) braziliensis being the major etiologic agent. The currently recommended therapy is limited by its parenteral use, high toxicity, and variable efficacy.[ncbi.nlm.nih.gov]
  • Individually and collectively, the identifying criteria implicate at least two L. braziliensis subspecies as etiologic agents of mucocutaneous leishmaniasis in Colombia and suggest that a spectrum of intrinsically distinguishable organisms may be involved[ajtmh.org]
  • ., An assay for circulating antibodies to a major etiologic virus of human non-A, non-B hepatitis, Science, 244, 362, 1989. ‎[books.google.de]
  • […] may appear on the tongue, buccal or nasal mucosa, and pharynx; many variants of the disease exist, marked by differences in distribution, vector, epidemiology, and pathology, which suggest that it may in fact be caused by a number of closely related etiologic[medical-dictionary.thefreedictionary.com]

Epidemiology

  • Abstract Leishmaniasis is a parasitosis with high prevalence and increasing epidemiologic relevance.[ncbi.nlm.nih.gov]
  • The practical aims are to encourage the application of these and other molecular epidemiological methods in S.[cordis.europa.eu]
  • Despite the propensity for clonality, hybrids are also an important feature of Leishmania (Viannia) and may give rise to epidemiologically important emergent genotypes.[ncbi.nlm.nih.gov]
  • OBJECTIVE: Our purpose was to develop a system for staging mucocutaneous leishmaniasis on the basis of clinical, histopathologic, epidemiologic, and immunologic criteria.[ncbi.nlm.nih.gov]
  • Although some studies have been carried out in areas of the country with a similar disease/ecological profile this report is, to our knowledge, the first aimed at elucidating the clinical-epidemiological features of cutaneous and mucocutaneous leishmaniasis[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • Jump to: navigation, search Leishmaniasis Microchapters Home Patient Information Overview Historical Perspective Classification Pathophysiology Causes Differentiating Leishmaniasis from other Diseases Epidemiology and Demographics Risk Factors Natural[wikidoc.org]
  • . ________________________________________ Pathophysiology • The parasite occurs in the amastigote form in the vertebrate host and in the promastigote form in the sandfly vector and on culture. • The promastigotes inoculated by the sandfly vector enter[leishmaniasis.info]
  • Pathophysiology Modes of transmission In leishmaniasis, the obligatory intracellular protozoa are transmitted to mammals via the bite of the tiny 2- to 3-mm female sandfly of the genus Phlebotomus in the Old World (Eastern Hemisphere) and Lutzomyia in[emedicine.medscape.com]
  • The etiology and pathophysiology of post-kala azar dermal leishmaniasis are not elucidated.[antimicrobe.org]

Prevention

  • Research on the immune response has been interesting, and vaccine prevention and treatment are objects of current interest. American leishmaniasis may not always remain a sylvan disease, and urban adaptation is a distressing possibility.[ncbi.nlm.nih.gov]
  • In spite of the presence of immunity in MCL, this is not sufficient to stop disease progression and prevent resistance to treatment.[ncbi.nlm.nih.gov]
  • Mucocutaneous Leishmaniasis (ML) can lead to serious sequela; however, early diagnosis can prevent complications. AIM: To evaluate clinical markers for the early diagnosis of ML.[ncbi.nlm.nih.gov]
  • The majority of New World CL (NWCL) types require systemic treatment (mainly with pentavalent antimonials), either to speed the healing or to prevent dissemination to oral-nasal mucosa as MCL (NWMCL).[ncbi.nlm.nih.gov]
  • If mucocutaneous leishmaniasis is suspected, otorhinolaryngologic examination is very helpful in establishing a correct diagnosis, preventing inappropriate treatment.[ncbi.nlm.nih.gov]

References

Article

  1. Palumbo E. Treatment strategies for mucocutaneous leishmaniasis. J Glob Infect Dis. 2010;2(2):147-150.
  2. Elmahallawy EK, Sampedro Martinez A, Rodriguez-Granger J, et al. Diagnosis of leishmaniasis. J Infect Dev Ctries. 2014;8(8):961-972.
  3. Masmoudi A, Hariz W, Marrekchi S, Amouri M, Turki H. Old World cutaneous leishmaniasis: diagnosis and treatment. J Dermatol Case Rep. 2013;7(2):31-41.
  4. Davies CR, Kaye P, Croft SL, Sundar S. Leishmaniasis: new approaches to disease control. BMJ. 2003;326(7385):377-382.
  5. World Health Organization. The world health report. Geneva: WHO; 2002. Annex 3: Burden of disease in DALYs by cause, sex and mortality stratum in WHO regions, estimates for 2001; pp. 192–197.www.who.int/whr/2002/whr2002_annex3.pdf
  6. Alvar J, Vélez ID, Bern C, et al. Leishmaniasis worldwide and global estimates of its incidence. PLoS One. 2012;7:e35671.
  7. Savoia D. Recent updates and perspectives on leishmaniasis. J Infect Dev Ctries. 2015;9(6):588-596.
  8. Diniz JL, Costa MO, Gonçalves DU. Mucocutaneous Leishmaniasis: clinical markers in presumptive diagnosis. Braz J Otorhinolaryngol. 2011;77(3):380-384.
  9. Lemrani M, Hamdi S, Laamrani A, Hassar M. PCR detection of Leishmania in skin biopsies. J Infect Dev Ctries. 2009;3(2):115-122.

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Last updated: 2019-07-11 20:22