Cutaneous leishmaniasis: an overview.

Leishmaniasis is a major world health problem, which is increasing in incidence. In Northern Europe it is seen in travellers returning from endemic areas. The protozoa is transmitted by sandflies and may produce a variety of clinical syndromes varying from a simple ulcer to fatal systemic disease. This review considers the management of simple cutaneous leishmaniasis. Patients usually have a single ulcer that may heal spontaneously, requiring only topical, or no treatment at all. Lesions caused by Leishmania braziliensis may evolve into the mucocutaneous form, 'espundia', and should be treated with systemic antimony. Sodium stibogluconate 20mg/kg/day i.v. for 20 days is the appropriate first line treatment in these cases. Although it may cause transient bone marrow suppression, liver damage, a chemical pancreatitis, and disturbances in the electrocardiogram, it appears safe. The success of treatment should be assessed 6 weeks after it has been completed and patients should be followed up for 6 months.

The management of cutaneous leishmaniasis from Belize.

We report 20 patients who contracted cutaneous leishmaniasis in Central and South America, 18 of them in Belize. The diagnosis was confirmed by the polymerase chain reaction (PCR) in 79% of those tested; the corresponding figure for histology was 62%, touch smear 46%, and culture 11%. Results of PCR can be falsely positive, so treatment should not be based on PCR alone. Of the 20 cases 18 were healed 6 weeks after intravenous sodium stibogluconate 20 mg/kg per day for 20 days. We present a management protocol.

Management of cutaneous leishmaniasis.

There is an urgent need for a safe, effective, easily administered and cheap treatment for cutaneous leishmaniasis. Unfortunately it remains elusive. There have been a number of contributions during the last year, but none will change present day management. The diagnosis of cutaneous leishmaniasis is established on the basis of a typical lesion, a history of exposure and demonstration of the parasite. Molecular methods, usually based on kinetoplast DNA, are being developed and used increasingly to diagnose and type the infecting organism. Pentavalent antimonials remain the mainstay of treatment.

Cutaneous leishmaniasis.

Leishmaniasis is a major World health problem, which is increasing in incidence. In Northern Europe it is seen in travellers returning from endemic areas. The protozoa is transmitted by sandflies and may produce a variety of clinical syndromes varying from a simple ulcer to fatal systemic disease. This review considers the management of simple cutaneous leishmaniasis. Patients usually have a single ulcer which may heal spontaneously, requiring only topical, or no treatment at all. Lesions caused by Leishmania braziliensis may evolve into the mucocutaneous form, 'espundia', and should be treated with systemic antimony. Sodium stiboglucoante 20 mg/kg/day i. v. for 20 days is the appropriate first line treatment in these cases. Although it may cause transient bone marrow suppression, liver damage, a chemical pancreatitis, and disturbances in the electrocardiogram, it appears to be safe. The success of treatment should be assessed 6 weeks after it has been completed and patients should be followed up for 6 months.

250 years of military dermatology: the British Army experience.

The British Army has encountered significant morbidity due to skin disease from the eighteenth century to the present time. The young age and pre-deployment screening of soldiers coupled with adverse environmental conditions produce a predominance of infective and eczematous conditions. The dermatologist still has a significant contribution to make in keeping the individual soldier healthy.

The association of hepatitis C viral infection with porphyria cutanea tarda in the Lothian region of Scotland.

Porphyria cutanea tarda (PCT) is believed to be associated with reduced hepatic uroporphyrinogen decarboxylase activity and risk factors such as alcohol abuse and medication with oral contraceptives and certain other drugs. Recently it has been suggested that hepatitis C virus (HCV) infection may also be associated with PCT. We have therefore reviewed the prevalence of HCV infection in a series of patients with PCT in the Lothian region of Scotland. We identified 12 patients with PCT, all of whom had abnormal liver function tests. Liver histology revealed chronic active hepatitis in six patients, micronodular cirrhosis in four patients, hepatocellular carcinoma in one patient and normal findings in one HIV positive patient. Out of 12 patients tested, 11 were positive for anti-HCV antibodies by second generation enzyme linked immunosorbent assay (ELISA 2), and by recombinant immunoblot assay (RIBA 2); positive serology was confirmed by polymerase chain reaction (PCR). In a second group of 14 patients with chronic HCV infection matched for age and sex with the PCT patients, all had normal urinary uroporphyrin excretion. We have thus confirmed in Scotland early reports from Spain and Italy that PCT is strongly associated with HCV infection. This could explain the development of inflammatory changes in the liver and progression of liver disease in patients with PCT. Porphyrin metabolism, however, appears normal in patients with chronic HCV infection without PCT.

Cutaneous myiasis due to Dermatobia hominis: a report of six cases.

We report six cases of Dermatobia hominis myiasis imported into the U.K. from Belize. With increasing international travel, myiasis may be encountered more frequently in countries in which the parasites are not indigenous. The life-cycle of D. hominis is described, and scanning electron micrographs show the detailed appearance of the larva.

Chronic bullous dermatosis of childhood: relapse after puberty.

Chronic bullous dermatosis of childhood (CBDC) is a distinctive subepidermal blistering disorder that characteristically involves the perioral area, lower trunk, inner thighs and genitalia. Direct immunofluorescence shows a linear band of IgA at the dermoepidermal junction (DEJ). The eruption usually begins before the age of 6 years and is typically described as self-limiting, clearing with a few months or years. Chronic bullous dermatosis of childhood has many clinical and immunopathological similarities with adult linear IgA disease (LAD) and it has been suggested that they represent different manifestations of the same disease. We report a case of CBDC which started at 2 years of age and which has relapsed twice, first at age 6 years and then again, after puberty, at age 17 years.

A clinico-pathological study of cutaneous leishmaniasis in British troops from Belize.

Thirty-four cases of cutaneous leishmaniasis contracted by British soldiers in Belize were studied. Pre- and post-treatment biopsies were taken from all patients. The range of histological appearances is described and the value of histological examination (including Giemsa staining and immunohistochemistry), cytological preparations and microbiological culture in diagnosis and clinical management assessed. Histology and culture were found to be complementary techniques in reaching a positive diagnosis, whilst cytological preparations were of no additional value. Histological examination of post-treatment biopsies merely confirmed the clinical impression of healing or non-healing whilst culture identified viable organisms in apparently healed lesions, which were subsequently re-treated.

Aminosidine (paromomycin) versus sodium stibogluconate for the treatment of American cutaneous leishmaniasis.

The efficacy of aminosidine was compared with sodium stibogluconate in an open, randomized study of parasitologically-proven cutaneous leishmaniasis in Belize. Aminosidine, 14 mg/kg/d (max. 1 g daily) for 20 d, healed 10 of 17 lesions and sodium stibogluconate, 20 mg/kg/d for 20 d, healed 15 of 17 lesions. Lesions caused by Leishmania braziliensis were relatively unresponsive to aminosidine. Aminosidine was well tolerated and toxicity was not observed. Sodium stibogluconate was not well tolerated and treatment was associated with bone marrow suppression and elevation of serum aminotransferases.

Cardiac effects of sodium stibogluconate: myocardial, electrophysiological and biochemical studies.

The pentavalent antimonial sodium stibogluconate is the mainstay of anti-leishmanial therapy. Sodium stibogluconate is less cardiotoxic than antimony and the trivalent derivatives, but has been associated with dose-related electrocardiographic changes. The effect of the currently-used regimen of sodium stibogluconate (20 mg/kg/day for 20 days) on cardiac function is uncertain. We studied 12 soldiers, mean age 24 years, with proven cutaneous leishmaniasis treated with this regimen. There were no significant changes in echocardiographic indices of left ventricular systolic or diastolic function during treatment. Indices of myocardial electrical stability (heart-rate variability and episodes of overt supraventricular and ventricular arrhythmias) were unchanged, but there was a reversible decrease in T-wave amplitude during treatment. Systolic and diastolic blood pressure fell and the heart rate increased during treatment. This regimen of sodium stibogluconate does not measurably impair left ventricular systolic or diastolic function. Minor T-wave changes occur during treatment, but there is no increase in arrhythmia frequency or change in heart-rate variability. In most young fit patients, this regimen has no cardiac side-effects. However, idiosyncratic reactions cannot be excluded, and patients with malnutrition, impaired renal function or pre-existing heart disease may be more sensitive to any cardiotoxic properties of sodium stibogluconate.

Hepatotoxicity of sodium stibogluconate therapy for American cutaneous leishmaniasis.

Sodium stibogluconate is the mainstay of treatment for all forms of leishmaniasis. Therapy is associated with an increase in serum aminotransferases. In this study liver damage was assessed during treatment of American cutaneous leishmaniasis with sodium stibogluconate and also in a control group given aminosidine. In addition to standard liver function tests, acute hepatocellular damage was assessed by measuring plasma glutathione S-transferase B1 (GST), and hepatic metabolic capacity was assessed by a caffeine clearance (CCL) test, before, during and after treatment. Thirteen patients were treated; 5 received sodium stibogluconate, 6 received aminosidine and a further 2 patients received aminosidine followed by sodium stibogluconate. Treatment with sodium stibogluconate was associated with an increase in both alanine aminotransferase (ALT) and GST and a fall in the CCL, indicating both hepatocellular damage and functional impairment. Six weeks after treatment had stopped ALT and GST had returned to pre-treatment levels and the CCL remained depressed in only one patient. Patients given aminosidine did not show any evidence of liver damage. Sodium stibogluconate is associated with significant hepatocellular damage and hepatic functional impairment. However, this is rapidly reversible on drug withdrawal. We suggest that liver function is monitored throughout treatment and that patients with pre-existing liver disease receive alternative treatment.

The role of skin biopsies in bone marrow transplant recipients.

Bone marrow transplant (BMT) recipients frequently develop rashes as a consequence of their disease, its treatment or because of a complication such as infection. These rashes are often clinically atypical, yet appropriate management is dependent upon correct diagnosis and therefore a skin biopsy is often performed. In a group of 101 consecutive BMT recipients, 25 patients had a total of 34 skin biopsies. A specific histopathological diagnosis was made in 65% (22/34), including graft vs. host disease (GVHD) (15 cases), infection (4 cases), drug reaction (1 case) and recurrent lymphoma (1 case). Therapy was changed following the biopsy in 77% (17/22) of these cases. In 35% (12/34) the histological changes were non-specific, however, in 10 of these cases GVHD had been suspected clinically and its exclusion was therefore useful. Skin biopsy is of considerable value in the diagnosis and subsequent management of BMT recipients who develop a rash.

Cutaneous leishmaniasis in British troops from Belize.

The medical records of 306 British soldiers in whom a clinical diagnosis of cutaneous leishmaniasis had been made following a tour of duty in Belize were analysed. Parasitological confirmation of the diagnosis was established in 187 cases; leishmania were cultured in 117 cases and Leishman-Donovan bodies were identified histologically in a further 70 cases. Leishmania braziliensis braziliensis was identified in 78 cases and Leishmania mexicana mexicana in a further 29 cases. Seventy-one per cent of patients had a single lesion which, in most cases, occurred on the exposed extremities. The mean diameter of the ulcers was 14.4 mm. Treatment with sodium stibogluconate was effective. Two regimens were used, consisting of either 600-800 mg daily given initially for 10 days, or 600 mg b.d. given initially for 14 days. Of those allocated to the lower dose regimen 48.5% were cured after the initial 10-day course, and ultimately the ulcers of 93% of patients healed following more prolonged treatment at this dose. Of those allocated to the higher dose regimen 63.9% were cured after the initial 14-day course and ultimately the ulcers of all patients healed after more prolonged treatment at this dose. A transient leucopenia and a rise in liver enzymes were noted during treatment, and these changes were dose-dependent. No cases of mucocutaneous leishmaniasis were encountered.