cutaneous leishmaniasis


introducedon :

Cutaneous Leishmaniasis (LC) can be defined as zoonoses resulting from the parasitism of the vertebrate host by a flagellate protozoan of the genus Leishmania, transmitted by the bite of an insect vector : sandfly

Épidémiologie :

  • Agent pathogenic :  flagellate protozoan of the order Kinoplastidae  and the family Trypanosomidae, is in 2 forms :

Amastigote :  immobile,  intracellular reticulohistiocytic system of vertebrates, corpuscolo ovoïde dépourvu de flagelle externe

Promastigote : highly mobile, encountered in the gut of the sandfly and the culture medium, having a free anterior flagellum that allows it to move actively

  • taxonomy : from the description of the first kind Leishmania Laveran and Mesnil 1903, the number of taxonomic entities increased to thirty, line surtout aux Méthodes de électrophorèse des isoenzymes and the Deutsch de la biologia molecolare

cash  normally  officials  from  leishmaniasis  visceral :  they can sometimes cause cutaneous leishmaniasis without visceral involvement :  L. infants (Mediterranean, some homes in the Middle East and South Asia), L. donovani

cash officials from leishmaniasis integumentary :

  • Former world : L. major (widespread in the Maghreb (Algeria, Morocco, Tunisia) and the Middle East), L. tropica, L. aethiopica (Ethiopia, Kenya)
  • New world : L. braziliensis (most prevalent in Latin America), L. guyanensis, L. panamensis, L. Mexican
  • Vector : arthropode : female sandfly
  • Tank : wild rodents, gophers (jirds chaoui), dog, chat…
  • Cycle of parasite :

➢ When an infected fly takes a blood meal in a mammalian host, she saliva puncture site and regurgitates, at the same time, the parasite promastigote form in its

➢ The parasite wins the cells of the reticuloendothelial system and is transformed into amastigote, ensues a parasite multiplication and lysis of the phagocyte, the released parasites are swallowed up by the cells avoisines

➢ The cycle is completed when a fly takes a blood meal and aspires phagocytes containing Leishmania, in the digestive tract of the arthropod, parasites differ, again, in promastigotes

  • Frequency : endemic in 88 pays, Algeria : 30.000 case (2005)
  • Division geographical : it is global :

Former world : Mediterranean Basin, south of the former USSR, Turkey, East Asia (in), Africa (Algeria, Morocco, Tunisia, Niger, Chad, Nigeria…)

New world : Latin America (Argentine, Mexico)

Algeria : long confined in the historic home of Biskra, disease known for twenty years a straightforward extension to the highlands and the north

CLinique :

  • Type description : ulcerative crusty leishmaniasis (Oriental button, nail Biskra)

Incubation : 2-3 month (from 8 days to months)

Button orient :

  • Seat : uncovered parts (face, mains, forearm, legs)
  • Lesion elementary :

At  beginning :  small papules CASTROTHEODORICIENNE,  dark red,  sometimes with pustular summit, single or multiple. In ten days, ulceration is constituted, is the nodule ulcerative scabby :

Nodule : from 2-3 cm diameter, badly limited, movable relative to the deep planes, the center is hollowed by ulceration usually hidden by a crust

Croute central : adherent, brownish yellow, thick, peel shows filiform extensions stalactites, on the underside

Ulceration : rounded or oval, from 1 several centimeters in diameter, edges cut perpendicularly, with grainy background and purulent, it can be spread or surface and burrowing

signs Related : no pain or itching, no lymphadenopathy or lymphangitis unless superinfection

  • shapes clinics of button orient :

leishmaniasis lupoid : particular form, common, papule or nodule, purplish or yellowish pink, smooth surface or squamo-crusty

  • Vitropression : lupus-like hue (yellowish)

Form impétiginoïde : squamo-crusty lesion spread, resting on a red skin, sometimes some very superficial ulcerations

Form   warty :   well plate projecting limited ±,   in papillomatous area, hyperkératosique, often dry

Form pseudotumoral : exuberant lesion

Form sporotrichosique : result of lymphatic dissemination of leishmania, giving abscesses in the lymph path

Other forms : New World (Latin America)

  • Form cutaneous diffuse (pseudo Lepromatous) : nodules, isolated, many
  • leishmaniasis mucocutaneous

ISevolution :

  • In general, persistent and stable, becoming steady after a few weeks of evolution
  • Spontaneous recovery occurs after about a year, the price of a depressed scar
  • No healing in 5% cases -> leishmaniasis chronic or recurrent cutaneous

Diagnostic positive :

  • elements anamnestiques : notion of living in an endemic area, insect bite, resistance to antibiotic and antiseptic treatment
  • elements clinics : painless nature of the injury despite the red hue, no lymphadenopathy or lymphangitis, headquarters in open areas
  • elements scalable : torpid evolution, persistent and stable in the absence of treatment
  • elements paracliniques :

exams parasitological : often possible to establish a definite diagnosis

  • Exam direct at microscope optical : sample, smear scraping, serum collected after scarification or biopsy of a lesion edge + histological section

Coloration MayGrunwaldGiemsa : body intracellular Leishman

Culture : culture of the biopsy specimen on the middle Navy Mc Neal Nicolle or rabbit serum (IPA)  -> results in 3-15 days,  interesting for pauci-parasitic forms

Histopathologie :

  • In  the  form  usual :  the dermis is the seat of polymorph inflammatory granuloma, in which coexists epithelioid cells + plasma cells that is evocative. Coloration au MGG -> corps de Leishman
  • In the form lupoid or recurrent : aspect of tuberculoid granuloma, lymphocytic infiltrate large with giant cells and rare epithelioid cells and histiocytes. The parasites are rare

exams immunological :

  • Intradermoréaction from Montenegro : its positivity persists for many years for a retrospective diagnosis
  • serology (indirect immunofluorescence ELISA) : detects circulating antibodies, often negative in cutaneous leishmaniasis, it has an interest especially in the Kala Azar

exams through PCR : raises awareness research and species identification

Typing of the leishmanies : from culture parasites -> epidemiological and scientific interest ; isoenzyme electrophoresis allows species diagnosis

Diagnostic differential :

  • In front of to form usual of button orient : it eliminates especially skin infections (boil, ecthyma, anthrax, atypical mycobacteria ...), rarely : carcinomas, lymphomas, foreign body granuloma
  • In front of the form lupoid : sarcoidosis in its angio-Lupoid, tuberculous lupus myxoma, tuberculoid, lupus-like rosacea

Traitement :

  • arms therapeutic :

treatments general conventional :

  • Antimoniate from Nmethyl-glucamine (Glucantime®) :

Presentation : 1 bulb 5 ml containing 1.5 g of total product, 1 ampoule contains 1/3 the active product (425 mg)

Dosage :

Adult : 60 mg / kg / day of total product or 20 mg / kg / day of active substance

Child : 30 mg / kg / day of total product or 10 mg / kg / day of active substance

Diagram therapeutic : J1 -> ¼ of the total dose IM, J2 -> ½ of the total dose IM, J3 -> ¾ of the total dose IM, J4 -> the total dose IM. Make a first cure 15 days followed by a washout 15 days, a second treatment may be necessary

Effects secondary :

signs  from  antimonyintolerance (anaphylactic) :  skin rash,   chills,   hyperthermia,   myalgie,   arthralgie,   diarrhea, vomiting, bulbar syndrome, whooping cough, tachycardia, lipothymie, bleeding. They may occur with the first dose -> permanent discontinuation

signs of stibio-poisoning : cardiac involvement (myocardite, arrhythmias),  liver disease and pancreatic,  kidney damage (tubular and glomerular), hematologic accident (pancytopénie), polyneuropathy. These signs appear during or even at the end of treatment (overdose)

with pretreatment : renal function (urea, creatinine, urine chemistery), liver function (TGO, TGP, phosphatases alcalines), NFS, crase sanguine, ECG, CXR

Cons-indications : heart disorders (arrhythmias, FATHER), kidney disease or severe hepatic, haemorrhagic syndrome, active pulmonary tuberculosis

Surveillance of treatment : ECG (QT prolongation, inversion of the T wave), NFS, liver function, renal function

  • Other :

Pentamidine (Lomidine®) : injection ampoule 300 mg, 3-4 mg / kg / j an IM, 1 day / 2, risque Collapse, neurite toxicity and induction of diabetes (5%)

Amphotéricine B  (Fungizone®) : the bottle 50 mg / ml for hospital use, adult : 1 mg/kg/j, child : 0.5 mg/kg/j, IV infusion, dilute 500 cc serum glucose 5%, it starts at an initial dose of 0.1 mg / kg / d to increase by weekly bearing 0.1 mg / kg / day until a dose of 1 mg/kg/j. Its high toxicity limits its use

treatments   general   alterative :   Fluconazole,   Trimethoprim sulfamethoxazole +

(Bactrim®), metronidazole (Flagyl®), ketoconazole (Nizoral®), Chloroquine (Nivaquine®)

Treatment local :

  • Infiltrateion intralesional from Glucantime® : if single lesion or 2 injury, 1-2 ml (depending on the size of the lesions) to the 4 cardinal points of the lesion 1 cm from the edges, 1 at 2 once a week for several weeks, do not use near the eye, peri-orificial, periarticular or lymphatic route
  • Treatment  physique :  electrocoagulation,  cryotherapy isolated or associated with the chemotherapy
  • Surgery : curatively (if a single lesion) or repairer title (and scarring unsightly)
  • Other :  formulation of topical aminoglycosides (Paromomycine et Gentamycine), applied under occlusive dressing
  • Indications :

leishmaniasis cutaneous localized :

  • Abstention therapeutic : Simple forms L. major an arm or leg
  • Treatment  local  (infiltration) :  if two single lesion or lesions,  without lymphatic spread, seat away from areas peri-orificial or periarticular. Other local means : cryothérapie, thermotherapy, surgical excision
  • Treatment through way General : recurrent cutaneous leishmaniasis, contraindication Local treatment, immunocompromised

leishmaniasis cutaneous disseminated : Glucantime® systemically first line. If failure : Pentamidine, Fluconazole, Flagyl®, ketoconazole, Fungizone®

  • Treatment preventif :

Fight against the vector : insecticides,  nets, wearing clothing covering the maximum body surface area

Fight  against  the  tank :  very difficult,  their destruction by deep plowing, poisoning, the clearing of peri-urban areas have not yielded the expected results

Vaccination : no vaccine is available