Cutaneous leishmaniasis due to
Leishmania aethiopica
Clinical presentations & complications
Mesfin Hunegnaw, MD
July 2011,...
Leishmania aethiopica
• It is the dominant species causing Cutaneous
leishmaniasis (CL) in Ethiopia
• Clinical subtypes:
-...
Localized cutaneous leishmaniasis
 Incubation period variable, usually several weeks
 Infection may be subclinical or cl...
Localized cutaneous leishmaniasis
 When it ulcerates it forms central depression and
raised indurated border
 Nodules pl...
Localized cutaneous leishmaniasis
 Some patients have more than one primary lesion
 Lesions are not always well-defined
...
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
– Sever...
Diffuse cutaneous leishmaniasis
• L. aethiopica
• Initial lesion may be small and well-defined
• Then multiple nodular & i...
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 infe...
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...
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...
Antimonials
• Have efficacy against L. aethiopica
• Localized lesions respond well
• Established MCL or diffuse leish resp...
Summary
• L. aethiopica is not a benign species
• Severe disease is probably underestimated as stigma might
cause social i...
Leish clinicaldrmesfin
Leish clinicaldrmesfin
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Leish clinicaldrmesfin

  1. 1. Cutaneous leishmaniasis due to Leishmania aethiopica Clinical presentations & complications Mesfin Hunegnaw, MD July 2011, Addis Ababa
  2. 2. Leishmania aethiopica • It is the dominant species causing Cutaneous leishmaniasis (CL) in Ethiopia • Clinical subtypes: - Localized CL - Mucocutaneous - Diffuse
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 2 large lesions, both poorly defined. Only showed partial response to parenteral antimonial at end of 2nd cycle
  7. 7. Inadequate treatment resulting in leishmaniasis recidivans: This will now be difficult to treat
  8. 8. 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
  9. 9. 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
  10. 10. Diffuse CL very disfiguring and treatment unresponsive
  11. 11. Ulcerative DCL
  12. 12. Ulceration, Contracture and deformity of the fingers
  13. 13. Extensive scaring, deformity & contractures
  14. 14. 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
  15. 15. Mucosal spread with lesions Naso-pharinigeal area
  16. 16. Spread of facial lesion to lower lip mucosa with oedema
  17. 17. Mucosal spread with severe facial lymphoedema developed one year after scar healed
  18. 18. Scarring from previous lesions. Patient now complains of nasal stuffiness & epistaxis
  19. 19. Untreated facial lesion self-healed. Patient now has mucosal disease affecting lips
  20. 20. Although lesion is defined patient is c/o of nasal congestion
  21. 21. 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
  22. 22. HIV -ve. Lesions still very active. c/o epistaxis
  23. 23. HIV positive. Palate also affected
  24. 24. HIV -ve. Previously healed facial lesions with scarring. Active mucosal disease
  25. 25. Also has active lesions over hands associated with severe scarring and deformity
  26. 26. Goals of therapy • Accelerate healing • Minimize scarring • Prevent complications • Prevent disease progression • Decrease risk of relapse
  27. 27. 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
  28. 28. 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
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