Psycho-social impacts, experiences and perspectives of patients with Cutaneous Leishmaniasis regarding treatment options and case management: An exploratory qualitative study in Tunisia.

Although non-fatal and mostly self-healing in the case of Leishmania (L.) major, cutaneous leishmaniasis (CL) is mainly treated to reduce lesion healing time. Less attention is paid to the improvement of scars, especially in aesthetically relevant areas of the body, which can dramatically affect patients' wellbeing. We explored patients' perspectives about treatment options and the social and psychological burden of disease (lesion and scar). Individual in-depth interviews were conducted with ten confirmed CL patients at two L. major endemic sites in Southern Tunisia (Sidi Bouzid and Gafsa). Participants were selected using a sampling approach along a spectrum covering e.g. age, sex, and clinical presentation. Patients' experiences, opinions and preferences were explored, and their detailed accounts gave an insight on the impact of CL on their everyday lives. The impact of CL was found to be considerable. Most patients were not satisfied with treatment performance and case management. They expected a shorter healing time and better accessibility of the health system. Tolerance of the burden of disease was variable and ranged from acceptance of hidden scars to suicidal thoughts resulting from the fear to become handicapped, and the stress caused by close relatives. Some believed CL to be a form of skin cancer. Unexpectedly, this finding shows the big gap between the perspectives of patients and assumptions of health professionals regarding this disease. This study provided valuable information for better case management emphasizing the importance of improving communication with patients, and accessibility to treatment. It generated context-specific knowledge to policy makers in Tunisia to implement effective case management in a country where access to treatment remains a challenge due to socio-economic and geographic barriers despite a long tradition in CL control.

Efficacy of fractional CO2 laser in treatment of atrophic scar of cutaneous leishmaniasis.

Cutaneous leishmaniasis is an endemic disease in Iran. Unfortunately, it can lead to unsightly atrophic scars with limited treatment options. Fractional CO2 laser is accepted for treatment of atrophic acne scars and recently has been used to treat cutaneous leishmaniasis, so we planned to use fractional CO2 laser on leishmaniasis scar. We conducted this study on 60 leishmaniasis scars on the face of 40 patients. The lesions were treated by a fractional CO2 laser with beam size of 120 µm, with energy of 50-90 mJ, and 50-100 spots/cm(2) density with two passes in three monthly sessions. Evaluation was done in the first and second months after the first treatment and 3 and 6 months after the last treatment. Digital photography was performed at each visit. Assessment of improvement rate by patient and physician was rated separately as follows: no improvement (0%), mild (<25%), moderate (25-50%), good (51-75%), and excellent (76-100%). Based on patients' opinion, in the first and second follow-up, 48.3 and 90% of them reported moderate to excellent healing, respectively (p < 0.001). In 3 and 6 months follow-up after the end of the experiment, most of the patients (88.3 and 95%, respectively) reported moderate to excellent healing of scars. Based on two observers' opinion, healing in the first follow-up in most of the patients (65%) was mild to moderate and 33% were reported as having no healing. In the second follow-up, only 5% of the patients were reported with no healing and 60% were reported as having moderate healing (p < 0.001). In 3 and 6 months follow-up, most of the patients (95 and 96.6%) were reported as having moderate to excellent healing (p = <0.001). Our results underlined the high efficacy of fractional CO2 laser for leishmaniasis scar. No significant adverse effects were noted.

Severe ocular sequelae of congenital toxoplasmosis: huge macular scar.

Retinochoroiditis is the most common ocular manifestation of congenital toxoplasmosis, but other associated ophthalmological pathologies can also occur. Ophthalmologists are rarely able to distinguish between toxoplasmic retinochoroiditis due to infection acquired before or after birth, unless other clinical or serological indications are present. This article reports a case of a 3-year-old boy with abnormalities suggestive of congenital toxoplasmosis. The clinical and complementary examinations are discussed. The education of pregnant women is crucial for the prevention of congenital toxoplasmosis. Awareness of antenatal and postnatal presenting signs and symptoms is important for clinicians, because early diagnosis and treatment may minimize sequelae. Untreated, the majority of affected infants will develop chorioretinitis, deafness and/or neurological symptoms.

Successful treatment of atrophic facial leishmaniasis scars by co2 fractional laser.

BACKGROUND: A permanent, unpleasant atrophic leishmaniasis scar is a potentially disfiguring condition that causes social stigma with limited treatment choices. Fractionated carbon dioxide (CO2) laser resurfacing is expected to be a safe and effective treatment for leishmaniasis scars. OBJECTIVE: To assess the safety and efficacy of ablative fractional resurfacing (AFR) with a CO2 laser for facial leishmaniasis atrophic scars. METHODS: Eleven patients (five males, age 18-47 years) underwent the fractional CO2 laser procedure. The mean duration for scars was 18.3 years. Three to five treatment sessions with the fractional laser eCO2 (10,600 nm, Lutronic Corporation, Gyeonggi-do, Korea ) were performed for each patient, at 2-month intervals, under topical anesthesia. Two passes (with tip type 120, density 150 spots/cm2 in static mode, and peak power of 30 watts) were performed on each leishmaniasis scar. Pulse energies ranged between 100 and 140 mJ. Posttreatment improvements in texture, atrophy, and overall satisfaction with appearance were graded on a quartile scale 1 month after the second session and 3 months after the final session. Scar improvement was graded using a 4-point score with a maximum score of 20. RESULTS: At the 3-month posttreatment follow-up, all subjects were rated as having at least 50% improvement in texture, atrophy, borders, and overall appearance of scars. The median score of improvement was 18 of 20 (range 11-19). Mild postinflammatory hyperpigmentation was the only adverse effect, observed in 18% (2 of 11) of subjects. After the procedure, moderate to severe erythema and edema typically resolved within 24 to 48 hours. No additional adverse effects were observed. CONCLUSION: Fractional CO2 resurfacing represents a safe, effective, and well-tolerated potential treatment for atrophic facial leishmaniasis scars in ethnic skin.

Single nucleotide polymorphisms in the interferon gamma gene are associated with distinct types of retinochoroidal scar lesions presumably caused by Toxoplasma gondii infection.

The association of single nucleotide polymorphisms (SNPs) in the interferon (IFN)-γ gene ( IFNG ) with different types of retinal scar lesions presumably caused by toxoplasmosis were investigated in a cross-sectional population-based genetic study. Ten SNPs were investigated and after Bonferroni correction, only the associations between SNPs rs2069718 and rs3181035 with retinal/retinochoroidal scar lesions type A (most severe scar lesions) and C (least severe scar lesions), respectively, remained significant. The associations of two different IFNG SNPs with two different types of retinal lesions attributable to toxoplasmosis support the hypothesis that different inflammatory mechanisms underlie the development of these lesions. The in vitro analysis of IFN-γ secretion by peripheral blood mononuclear cells stimulated with Toxoplasma gondii antigens was also investigated. The association between SNP rs2069718 and type A scar lesions revealed that differential IFN-γ levels are correlated with distinct genotypes. However, no correlation was observed with IFN-γ secretion levels and the SNP rs3181035 , which was significantly associated with type C scar lesions. Our findings strongly suggest that immunogenetic studies of individuals with congenital or postnatally acquired infection are needed to better understand the role of IFN-γ and its polymorphisms in the pathogenesis of ocular toxoplasmosis.

Single nucleotide polymorphisms in the interferon gamma gene are associated with distinct types of retinochoroidal scar lesions presumably caused by Toxoplasma gondii infection

The association of single nucleotide polymorphisms (SNPs) in the interferon (IFN)-γ gene ( IFNG ) with different types of retinal scar lesions presumably caused by toxoplasmosis were investigated in a cross-sectional population-based genetic study. Ten SNPs were investigated and after Bonferroni correction, only the associations between SNPs rs2069718 and rs3181035 with retinal/retinochoroidal scar lesions type A (most severe scar lesions) and C (least severe scar lesions), respectively, remained significant. The associations of two different IFNG SNPs with two different types of retinal lesions attributable to toxoplasmosis support the hypothesis that different inflammatory mechanisms underlie the development of these lesions. The in vitro analysis of IFN-γ secretion by peripheral blood mononuclear cells stimulated with Toxoplasma gondii antigens was also investigated. The association between SNP rs2069718 and type A scar lesions revealed that differential IFN-γ levels are correlated with distinct genotypes. However, no correlation was observed with IFN-γ secretion levels and the SNP rs3181035 , which was significantly associated with type C scar lesions. Our findings strongly suggest that immunogenetic studies of individuals with congenital or postnatally acquired infection are needed to better understand the role of IFN-γ and its polymorphisms in the pathogenesis of ocular toxoplasmosis.

Clinical manifestations of ocular toxoplasmosis.

Clinical manifestations of ocular toxoplasmosis are reviewed. Findings of congenital and acute acquired ocular toxoplasmosis include retinal scars, white-appearing lesions in the active phase often associated with vitritis. Complications can include fibrous bands, secondary serous or rhegmatogenous retinal detachments, optic neuritis and neuropathy, cataracts, increased intraocular pressure during active infection, and choroidal neovascular membranes. Recurrences in untreated congenital toxoplasmosis occur in teenage years. Manifestations at birth are less severe, and recurrences are fewer in those who were treated promptly early in the course of their disease in utero and in the first year of life. Severe retinal involvement is common at diagnosis of symptomatic congenital toxoplasmosis in the United States and Brazil. Acute acquired infections also may be complicated by toxoplasmic retinochoroiditis, with recurrences most common close to the time of acquisition. Suppressive treatment can reduce recurrent disease.

Signs of an in situ inflammatory reaction in scars of human American tegumentary leishmaniasis.

Skin inflammation plays an important role during the healing of American tegumentary leishmaniasis (ATL), the distribution of cells in active lesions may vary according to disease outcome and parasite antigens in ATL scars have already been shown. We evaluated by immunohistochemistry, 18 patients with 1- or 3-year-old scars and the corresponding active lesions and compared them with healthy skin. Small cell clusters in scars organized as in the active lesions spreaded over the fibrotic tissue were detected, as well as close to vessels and cutaneous glands, despite a reduction in the inflammatory process. Analysis of 1-year-old scar tissue showed reduction of NOS2, E-selectin, Ki67, Bcl-2 and Fas expression. However, similar percentages of lymphocytes and macrophages were detected when compared to active lesions. Only 3-year-old scars showed reduction of CD3(+), CD4(+) and CD8(+)T cells, in addition to reduced expression of NOS2, E-selectin, Ki67 and BCl-2. These results suggest that the pattern of cellularity of the inflammatory reaction observed in active lesions changes slowly even after clinical healing. Analysis of 3-year-old scars showed reduction of the inflammatory reaction as demonstrated by decrease in inflammatory cells and in the expression of cell-activity markers, suggesting that the host-parasite balance was only established after that period.

Evaluation of intralesional 0.2% ciprofloxacin as a treatment for cutaneous leishmaniasis.

Although cutaneous leishmaniasis lesions usually heal spontaneously they cause unsightly scarring. This study evaluated a possible new therapy in 38 patients, with 70 lesions, randomly assigned to intralesional injection of ciprofloxacin (0.2%) or intralesional sodium chloride hypertonic solution (7%). After excluding patients who defaulted on treatment, lesions assigned to sodium chloride treatment (n = 21) were completely healed (with or without scarring) in 76.2% of cases, and, when a scar remained, the scar size was reduced 66.0% compared with the original lesion. Lesions assigned to ciprofloxacin (n = 27) showed an 81.5% healing rate with an average scar size reduction of 68.6%. Intralesional 0.2% ciprofloxacin was as effective as hypertonic saline in the treatment of cutaneous leishmaniasis infection.

Leishmaniose tegumentar americana humana e canina no Município de Mariluz, Estado do Paraná, Brasil / Human and canine American cutaneous leishmaniasis in Mariluz, Paraná State, Brazil

Relata-se a ocorrência de um surto de leishmaniose tegumentar americana no ano de 2002, no Município de Mariluz, mesorregião noroeste do Estado do Paraná, Brasil. Das 38 pessoas investigadas, quatro tinham lesões cicatrizadas, 10 em cicatrização e 24 tinham lesões ativas. Dos 126 cães investigados, 20 (15,9 por cento) tinham lesões sugestivas e 24 (19 por cento) tiveram sorologia positiva. Os parasitos isolados de dois pacientes e de três cães foram identificados como Leishmania (Viannia) braziliensis serodema I. Os flebotomíneos coletados foram identificados como Nyssomyia whitmani, N. neivai e Migonemyia migonei. Considerando que a área onde ocorreram os casos é semelhante a outras de colonização antiga no Estado do Paraná, acredita-se que as alterações ambientais e as matas remanescentes propiciam a manutenção do ciclo enzoótico do parasito e a transmissão para o homem e para os animais domésticos, mantendo o caráter endêmico da leishmaniose tegumentar americana.

An outbreak of American cutaneous leishmaniasis was reported in 2002 in Mariluz, northwestern Paraná State, Brazil. Of 38 humans who were investigated, four had healed lesions, ten showed lesions in the healing process, and 24 had active lesions. Of the 126 dogs, 20 (15.9 percent) presented suggestive lesions and 24 (19 percent) had positive serology. Parasites isolated from two patients and three dogs were identified as Leishmania (Viannia) braziliensis serodeme I. The captured sand flies were identified as Nyssomyia whitmani, N. neivai, and Migonemyia migonei. Considering that the region where the cases occurred is similar to other old human settlements in Paraná State, the environmental alterations and remaining forests facilitate the maintenance of the parasite's enzootic cycle and transmission to humans and domestic animals, thereby maintaining the endemicity of American cutaneous leishmaniasis.

Evidence for leishmania (viannia) parasites in the skin and blood of patients before and after treatment.

BACKGROUND: American cutaneous leishmaniasis is considered to be a zoonotic disease transmitted by sand flies that feed on infected sylvatic mammals. However, the "domestication" of transmission and the increase in treatment failure with antimonial drugs have raised the suspicion of anthroponotic transmission of American cutaneous leishmaniasis. METHODS: The objective of the present study was to explore the potential of humans as a source of infection for sand flies. Biological (xenodiagnosis and culture) and molecular (polymerase chain reaction/Southern blot) detection methods were used to evaluate peripheral-blood monocytes and tissue fluids from sites accessible to sand flies from 59 adult patients with parasitologically confirmed American cutaneous leishmaniasis. RESULTS: Overall, 44.1% of patients (26/59) presented biological and/or molecular evidence of Leishmania parasites in normal skin, peripheral-blood monocytes, lesion scars, or lesion border (by xenodiagnosis) before (18/59 [30.5%]) or after (10/27 [37.0%]) treatment. Leishmania parasites were cultured from the unaffected skin of 2 (3.6%) of 55 patients, and xenodiagnosis gave positive results for 5 (8.8%) of 57 patients before treatment. CONCLUSIONS: The presence of Leishmania parasites in the unaffected skin and peripheral-blood monocytes of a high proportion of patients even after treatment and the acquisition of infection by sand flies support the plausibility of anthroponotic transmission of American cutaneous leishmaniasis.

Biocirugía: utilización de larvas de insectos necrófagos en la curación de heridas. La terapia larval / Biosurgery: use of larvae of necrophage insects in wound healing. The larval therapy

La terapia larval es una técnica que permite aplicar las larvas de algunas especies de dípteros sobre heridas crónicas o sobre focos de infección localizados, con la finalidad de restaurar el tejido afectado. La velocidad y la eficacia del tratamiento, sumadas a la casi nula pérdida de tejido sano durante el proceso de reparación tisular, han hecho de la terapia larval o biocirugía una alternativa viable para la curación de heridas asociadas con entidades como pie diabético, úlceras venosas, úlceras crónicas de la piel y quemaduras, así como de ciertos tipos de tumores beningos, abscesos y osteomielitis.Aunque la medicina moderna ha sido, en muchos casos, reticente a la aplicación de terapias de esta índole, eventos como la resistencia a los antibióticos y las alteraciones en el proceso de cicatrización en las heridas crónicas han permitido modificar la posición inicial de muchos médicos al respecto.

A new epidemic focus of zoonotic cutaneous leishmaniasis in central Iran.

BACKGROUND: Reports from the health center of Yazd province of increasing cutaneous leishmaniasis (CL) cases led us to carry out an epidemiological study using standard techniques in Ardakan County, central Iran, during 2001. PATIENTS AND METHODS: Data was collected on the prevalence of scars and ulcers over a period of 14 months among 621 households in three villages around Ardakan County. Smears were prepared by scraping the edges of the ulcers. We collected the same data on all school children aged 7 to 11 years old in the area. To determine the reservoir host of the disease, rodents and dogs were caught and examined. Sandflies were collected biweekly from indoor and outdoor locations in the study area, and then identified. Parasites isolated from human and rodents were characterized by RAPD-PCR technique. RESULTS: The prevalence of scars and ulcers were 30.4% and 24.6%, respectively, in 3024 individuals in the three villages. Individuals 10 to 14 years of age were the most highly infected age group, with a rate of 28.4%. Males and females were equally infected. Examination of 892 students in primary schools showed a rate of 22.9% for scars and 23.7% for ulcers. Meriones libycus (42.2%) and Rhombomys opimus (57.8%) were present around the villages. Both were infected with Leishmania. Three of 19 M. libycus (15.7%) and 3 out of 26 R. opimus (11.5%) had positive results. The active season of sandflies was late April to late November. Phlebotomus papatasi and Sergentomyia sintoni were the dominant species indoors and outdoors. Natural leptomonad infection was found in P. caucasicus and S. sintoni from gerbil and Jird burrows. CONCLUSION: Based on this survey, there is an epidemic of zoonotic CL in the area, with Leishmania major as the agent, M. libycus and R. opimus as the reservoir hosts, and most probably Phlebotomus papatasi as the vector because about 77% of indoor sandflies were of this species.

Persistence of leishmania parasites in scars after clinical cure of American cutaneous leishmaniasis: is there a sterile cure?

BACKGROUND: It is uncertain whether Leishmania parasites ever disappear after clinical cure of American cutaneous leishmaniasis (ACL). Recently, sensitive molecular techniques have allowed the identification of Leishmania parasites directly in specimens from patients' scars. METHODS: Scars of 32 patients from northeastern Brazil who were treated and clinically cured of ACL were analyzed by use of polymerase chain reaction (PCR), culture, and histopathologic examination. RESULTS: DNA specific for Leishmania (Viannia) was detected in scars of 30 (93.7%) of 32 patients. In specimens from 3 of the scars, Leishmania parasites could be isolated by culture; PCR results also were positive for those 3 specimens. No parasites were found by histopathologic examination, and fibrotic alterations were present in all cases, with slight inflammatory foci observed in 4 of the cases studied. CONCLUSIONS: The results suggest that clinical cure of ACL is rarely associated with sterile cure. The implications of persistence of parasites for the clinical evolution, relapse, and transmission of leishmaniasis deserves further studies, particularly with the increasing incidence of coinfection with leishmaniasis and acquired immunodeficiency syndrome.