CUTANEOUS LEISHMANIASIS

• This is leishmasis of the cutaneous layer of

the body.
• It is caused by a leishmaniae that is
morphilogically similar to L. donovani
• This leishmaniae is known to be responsible
for cutaneous lesions in various parts of the
world.
 CLASSIFICATION OF CUTANEOUS
LEISHMANIASIS.

• Cutaneous leishmaniasis is broadly classified

into two viz:
• (a) Old World cutaneous leishmaniasis and
• (b) New world cutaneous leishmaniasis.
 Old world cut. Leishmaniasis.
• The term old world refers to the countries along the Mediterranean
coast, the middle east and as far east as India.
• Old world Cutaneous leishmaniasis therefore refers to cutaneous
leishmaniasis found in those areas / part of the world refer to as old
world.
• The old world cutaneous leishmaniasis is caused by different species
of leishmaniae
• They include the following: (1) L.major (2) L .tropica and (3) L.
aethiopica

• In India the condition “cutaneous leishmaniasis’ is prevalent in the

North West particularly Rajasthan.
• It is called by various names such as oriental sore and by the names of
various places such as Delhi boil, Aleppo boil, Bagdad or Biskra button.
 New world cutaneous leishmaniasis

• The term new world refers to the South and

central America.
• In the New World, cutaneous leishmaniasis is
caused by (a) L. Braziliensis and (b) L.
Mexicana.
 Morphology and Life Cycle

• The morphology and life cycle of the different

species of leishmanae causing leishmaniasis
resemble those of L. donovani.
• The amastigote is found present in the
• (A) The skin: (i) Within large mononuclear cells and
neutrophils.
• (B) Inside capillary endothelial cells and
• (C ) Free in tissues.
 LIFE CYCLE
• They are ingested by sandflies feeding near
the skin lesions into the gut.
• In the midgut of the sandfly, the amastigotes
develop into promastigotes which replicate
profusely.
• These are in turn transmitted to the skin of
persons through the bite of the sandflies.
 LIFE CYCLE.

• In the skin: Promastigotes are phagocytosed by the

mononuclear cells.
• In the mononuclear cells they become Amastigotes
and multiply.
• They remain confined to the skin in the mononuclear
cells.
• They are not being transported to the internal organs
as is the case in visceral leishmaniasis
 Transmission of infection.

• Infection is transmitted through sandflies.

• Infection may also occur by direct contact.
• Infection may be transmitted from man to- man or
animal-to-man by direct inoculation of amastigotes
• Infection may also be mechanical with the sand-fly
acting as mechanical vector transmitting the
amastigote from a sore on a patient into the bite
wound on another person.
 Clinical Features and Epidemiology

• The clinical and epidemiological patterns of

Leishmaniasis vary from region-to-region. .
• In the Old World : Three distinct patterns of
cutaneous leishmaniasis are recognized viz:
(i) The anthroponotic urban type cutaneous
leishmaniasis.
(ii) The zoonotic rural type
(iii) The non-ulcerative and often diffuse
lesions.
 Clinical Features:
(anthroponitic urban type)
(a) The anthroponitic urban type: This is caused by
L. tropica.
• The incubation period for this is usually 2 to 8
months
• It develops as a painless dry ulcerating lesions,
which leads to disfiguring scars.
• It is commonly found in children in endemic area.
 Clinical Features
(anthroponitic urban type cont.)

• The dry ulcers usually heal spontaneously in about

a year.
• Old world cutaneous leishmaniasis is prevalent
from the Middle East to North Western India.
• The most important vector is P. sargenti.
 Clinical Features
b.(zoonotic rural type Leishmaniasis)

• (ii) The zoonotic rural type Leishmaniasis:

• This is seen in the lowland zones of Asia, Middle
East and Africa.
• It is caused by L. major. It manifest as a moist
ulcers which are inflamed
• The ulcers are usually multiple..
• The incubation period is usually less than 4 months.
 Clinical Features
(zoonotic rural type Leishmaniasis cont.)

• The ulcers heal in several months.

• This is seen in the lowland zones of Asia, Middle
East and Africa.
• Gerbils, rats and other rodents are the reservoirs.
• P.papatasi is the most important vector.
Clinical Features (c ) Non-ulcerative and often diffuse
lesion

This is caused by L. aethiopica .

• It is seen in the highlands of Ethiopia and
Kenya.
• The vector is P. longipes
 Clinical features. Cont.

• The oriental sore begins as a small papule.

• This gradually enlarges to form a raised indurated
lesion with surrounding erythema.
• The sore heals spontaneously in several months
• This leaves behind a slightly depressed papery
scar.
• The lesions occur mostly on the exposed parts of
the body, especially on the face and hands.
 DIAGNOSIS:

• (A )The diagnosis of Leishmaniasis is divided into

three.
• MICROSCOPY: This involves microscopic
examination of material obtained by puncturing
the edges of the lesion.
• This will show the amastigote form of the parasite.
• (B) CULTURE: The samples are Cultured on NNN
medium.
 Diagnosis cont.

©Serological test: This is important in the diagnosis

of leismaniasis.
• It is an intradermal test called Leishmanin test
• It is also referred to as Montenegro skin reaction
test.
• It is positive in cutaneous leishmaniasis.
 Diagnosis cont.
• When positive, It indicate good cell mediated
immunity to the parasite.
• Most cutaneous lesions heal spontaneously.
 TREATMENT:

• Leishmania can be treated using any of the

following drugs.
(i) Pentavalent antimonials: This is the drug of choice
for treatment.
(ii) Metronidazole.
(iii) Rifampicin
(iv) Aminosidine ointment has been found to be a
useful local treatment.
• Local application of heat has also given good
treatment results.
 IMMUNITY IN LEISHMANIASIS
• Patients suffering from leishmaniasis often develop cell
mediated immunity.
• Failure to do this may lead to diffuse cutaneous
leishmaniasis.
• This results in the development of numerous nodular
non-ulcerating lesions on the face and limbs,
• This resemble the lesions of lepromatous leprosy.
• American soldiers infected by L. tropica during the Gulf
war were reported to have developed viscerotropic
disease .
• This involves the lymph node and bone marrow.
 Leishmaniasis recidivans:

• This is a type of Leishmania sis /disease that

develops in persons with a high degree of cell-
mediated immunity .to the parasite.
• The lesions are usually chronic with alternating
periods of activity and healing.
• It is characterised by a central scar with peripheral
activity .
• The lesions resemble those of lupus or tuberculoid
leprosy.
• The parasites are very scanty in the lesions.
• In this condition, Leishmanin test is strongly
positive.
• Chemotherapy is not very useful.
• Better results follow local application of heat.
 New World Cutaneous Leishmaniasis

• In the New World ,two groups of leishmaniae causes

cutaneous lesions.
• They are ( i) L. Mexicana group (ii) ) L. Braziliensis and (iii)
L. .Guyanensis group.
• They cause
• (a) Cutaneous ulcers and occasionally
• (b) Diffuse cutaneous leishmaniasis.
• They may also cause cutaneous lesions which may lead to
mucocutaneous leishmaniasis or espundia.
 Mucocutaneous Leishmaniasis (ESPUNDIA)

• This is also called Espundia, caused by L. Donovanie

• In South America, it is seen as a late consequence of
cutaneous leishmaniasis.
• In mucocutaneous Leishmaniasis, there is development
of Granulomas at the mucocutaneous junctions.
• Usually this is around the nose and mouth.
• This is followed by gross destruction of soft tissue and
cartilage in this area leading to disfiguration.
• Secondary anaerobic bacterial infection adds to the
severity of the disease.