Dissemination in cutaneous leishmaniasis. 3. Lymph node involvement.

In a study of zoonotic cutaneous leishmaniasis (CL) due to leishmania major in an endemic focus in Saudi Arabia, lymph node enlargement was observed in 66 of 643 patients (10.26%). The epitrochlear lymph nodes were most commonly involved (68%), but cervical (11%), axillary (15%), and inguinal (18%) lymph nodes were also involved. In eight patients (12%), two lymph node areas were involved. The affected lymph nodes were typically solitary, firm, mobile, nontender, only moderately enlarged, and appeared to persist beyond the clinical healing of the associated skin lesions. The results of pathologic and immunopathologic studies carried out on eight lymph nodes obtained from this group of patients supported the leishmanial etiology. Although amastigotes were only demonstrated in two lymph nodes, the leishmanial antigen was found in all eight specimens. The lymph node involvement is another manifestation of dissemination in infection with a dermotropic leishmania. It appears that in some cases, instead of the parasite, it may be the leishmanial antigen that disseminates and produces lymphadenitis.

Dissemination in cutaneous leishmaniasis. II. Satellite papules and subcutaneous induration.

In a field study of cutaneous leishmaniasis (CL) due to Leishmania major, zymodeme Lon-4, in an endemic focus in Saudi Arabia, 80 patients in a group of 643 patients (12.44%) were found to have multiple, inflammatory, satellite papules (SP) around one or more CL lesions. The SP often appeared to erupt after commencement of antileishmanial treatment. They showed a range of morphology and pathology, and comparisons with corresponding CL lesions showed important differences. Amastigotes were seen in only one of seven biopsy specimens. Another morphologic feature, subcutaneous induration (SCI), was noted on routine palpation in 20 patients in the same patient group (3.11%). The SCI either was radiating all around the lesion and appeared as an "iceberg nodule" or was present as a "tonguelike" process proximal to the CL lesion. Amastigotes were seen in four of nine biopsy specimens of SCI. SP and SCI represent reactions to local dissemination of the parasite or its antigenic products, and as morphologic features aid in the clinical diagnosis of CL.

Unusual complications of Salmonella enteriditis group D infection.

A 25-year-old Syrian presented complaining mainly of fever, night sweats and nausea. He had 3 days earlier mild abdominal cramps and short-lived diarrhoea. On admission, he developed signs of deep vein thrombosis and blood and stool cultures showed Salmonella enteriditis infection. The patient was started on chloramphenicol and later showed acute abdominal signs. Laparotomy revealed intestinal perforation on the lower ileum. The case together with the experience in this hospital and elsewhere of Salmonella enteriditis infections are discussed, showing that two complications shown in this case are common for Salmonella typhi and paratyphi infections but are unusual for other Salmonella infections.

Peripheral nerve involvement in cutaneous leishmaniasis (Old World).

A review of 288 skin biopsy specimens from cutaneous leishmaniasis lesions caused by Leishmania major showed assorted nerve changes in 14 biopsy specimens (5%). Ten patients had perineural inflammatory cell infiltrate consisting of either lymphocytes or a mixture of lymphocytes, plasma cells, and macrophages. Four patients had inflammatory cell invasion of the nerves (neuritis), and in one of them the inflammation was granulomatous and associated with nerve destruction. Amastigotes were seen inside the nerves in two patients. Sensory testing of 50 consecutive patients with cutaneous leishmaniasis identified two patients with diminished sensations over the lesions.

Dissemination in cutaneous leishmaniasis. I. Subcutaneous nodules.

In a study of cutaneous leishmaniasis (CL) caused by Leishmania major in Saudi Arabia, 10% of the patients were found to have subcutaneous nodules (SCN). The SCNs were usually inconspicuous, painless, and proximal to the primary skin lesions; when multiple, they showed a "sporotrichoid" configuration or appeared as "beaded cords." Their number ranged from 1-16 (average 3 25 +/- 2.50; mean +/- 1 SD). In some patients, the SCNs seemed to be triggered by antileishmanial treatment. The clinical picture and pathologic findings suggest that SCNs in patients with CL represent lymphatic dissemination, a phenomenon not widely recognized.

Clinical diagnosis of cutaneous leishmaniasis (oriental sore).

Cutaneous leishmaniasis (oriental sore) is characterized by slowly evolving inflammatory lesion(s) that are nodular, noduloulcerative, or ulcerative and that heal spontaneously with scar(s) in 3 to 12 months. In the course of a comprehensive study of cutaneous leishmaniasis due to Leishmania major in an endemic focus in Saudi Arabia, seven clinical features of diagnostic value were identified and their approximate frequency in a selected group of 475 patients was determined. These features were: exposed site location, 84%; pairing or clustering of lesions, 61.72%; skin crease orientation, 35.37%; volcanic nodules, 30.32%; satellite papules, 19.37%; subcutaneous nodules, 11.37%; and "iceberg" nodules, 4.63%. This information should serve the process of clinical diagnosis and may be relied upon when the procedures for parasite detection are negative or unavailable.

Zinc and copper status in patients with sickle cell anemia.

Plasma zinc and copper concentrations were determined by atomic absorption spectroscopy in 57 patients with sickle cell anemia and in 45 control subjects from the Eastern Province of Saudi Arabia. Plasma zinc and copper levels in patients were found to be close to those of the control subjects. Similarly, there was a difference neither in urinary zinc level nor in the ratio Cu:Zn in patients and control subjects. This is in contrast to the situation which exists in North American Black subjects with sickle cell anemia, who are known to have zinc deficiency as well as a further decrease in zinc level during sickle cell crises. The near-normal levels of zinc and copper found in Saudi sickle cell patients therefore exclude zinc deficiency and confirm that this population exhibits a milder form of sickle cell anemia.

Glycosylated hemoglobin levels in a benign form of sickle cell anemia in Saudi Arabia.

Glycosylated hemoglobin was determined by the thiobarbituric acid method in sickle cell anemia patients from the Eastern Province of Saudi Arabia. The level of glycosylated hemoglobin in a Saudi SS sample (4.36%, SD 0.83) is 90% of that of the sample of normals (4.85%, SD 0.51). This is in contrast with the reported value of glycosylated hemoglobin in an American Black SS sample (3.9%, SD 0.6), which is only 60% of that of the sample of normals (6.6%, SD 0.7). The fetal hemoglobin level in Saudi sickle cell patients was 12.03% (SD 4.84), which is significantly different from that of Americans of African origin at p = 0.001. There was no significant correlation (r = 0.236) between the percentages of glycosylated Hb and Hb F at the 10% confidence level. The reported positive relationship between the percentages of glycosylated Hb and Hb F in American Blacks seems to be valid in the Saudi population only up to the level of 10-12% of fetal hemoglobin. Above this threshold of Hb F no further alleviating effect is seen. The 2,3-diphosphoglycerate value in Saudi Hb SS adults was 21.7 mumol/g (SD 7.4) and accordingly only twice as high as that of normal individuals. The benign clinical course exhibited by Saudi sickle cell patients is reflected by the survival of the RBC as indexed by its content of glycosylated Hb and 2,3-diphosphoglycerate. Moreover 10-12% of fetal hemoglobin in the RBC seems sufficient to ameliorate the severity of this disease in patients from the Eastern Province of Saudi Arabia.

Efficacy of metrifonate in urinary schistosomiasis: comparison of reduction of Schistosoma haematobium and S. mansoni eggs.

Patients with schistosomiasis mansoni and schistosomiasis haematobium from the Gezira area of the Sudan were investigated for the simultaneous presence of Schistosoma mansoni and S. haematobium eggs in urine. Before treatment, 28 or 34 mixed-infection patients constantly excreted eggs of S. mansoni in the urine; however, the concentration was only 1.7% that of S. haematobium eggs. Patients were given two doses of metrifonate (10 mg/kg body weight) 2 weeks apart in order to compare the effect of the organophosphorous compound on the two parasite species. Each dose of metrifonate was followed by a significant decrease in egg output in urine (P less than 0.01). The egg reduction was similar for both parasite species, and was almost 99% after the second treatment. Before treatment was started, a positive correlation existed between the numbers of S. haematobium and S. mansoni eggs excreted in urine (r = 0.75, P less than 0.001), and this correlation did not change after the first or the second dose of metrifonate. After treatment, in 6 of 37 patients S. haematobium eggs and in 8 of 28 patients S. mansoni eggs were not, or were only slightly, reduced. When chemotherapeutic failure of metrifonate against S. haematobium or S. mansoni occurred, it was quantitatively similar for both parasite species.

Efficacy of metrifonate in urinary schistosomiasis in light and heavy infections.

In a prospective clinical trial, patients with urinary schistosomiasis from the Sudan and from other African countries were treated with two or three doses of metrifonate (10 mg/kg), respectively, in two weeks' intervals. Patients seen in the Sudan (n = 37) were followed up for 3 months, those seen in Hamburg (n = 17) up to 20 months. Each dose of metrifonate led to a decrease of almost 90% in egg excretion independently of the pretreatment intensity of infection so that after three doses a reduction of almost 99.9% was achieved. The estimated proportion of parasitological cure after two doses of metrifonate was in the order of 24% in the lightly infected patients seen in Hamburg, and in the order of 8% in the heavily infected Sudanese patients. Almost 59% of the patients who received a complete metrifonate treatment of three doses stopped to excrete ova of S. haematobium. Drug failure was found in almost the same proportion in the two patient groups (17.5% and 16.2%, respectively) and could not be overcome by additional doses of metrifonate. The considerable reduction in egg excretion after a single dose of metrifonate might have a remarkable benefit in large scale programmes where the aim is drastic reduction of worm burden rather than complete cure.

A seroepidemiological survey in the Gezira, Sudan, with special reference to arboviruses.

A serological survey in the Gezira area of the Sudan confirmed that malaria and schistosomiasis were highly endemic. Of other parasitic infections amoebiasis was common but Toxoplasma was less than found in a previous survey. Poliomyelitis and measles infection were universal and there was an extremely high incidence of infection with hepatitis B. Of arboviruses infection with flaviviruses was frequent and more than with alphaviruses.

An assessment of anti-schistosomal treatment on physical work capacity.

Acting as their own controls, village subjects from the Gezira are of the Sudan with relatively high levels of schistosomiasis infection were first tested in an exercise laboratory in Khartoum and the tests were then repeated after a period of about 1 yr during which time the subjects were treated with hycanthone and periodically monitored to ensure that they had remained free of the disease. In the meantime they were also given anti-malarial prophylaxis. Laboratory tests showed a significant improvement in physiological work capacity of up to 20% after treatment compared with untreated controls. An overall improvement in pulmonary function, particularly forced vital capacity, was observed as well as a significant increase in mean haemoglobin concentration by 1.1 g/100 ml of blood in the treated group. Apart from these improvements in physical working capacity, the treated subjects subjectively felt better after the exercise tests, as expressed by the disappearance of fatiguability.

Praziquantel in the treatment of mixed S. haematobium and S. mansoni infections.

A randomized single blind stratified study involving 153 patients with mixed S. mansoni and S. haematobium infection showed that 2-cyclohexylcarbonyl-1,2,3,6,7,11b-hexahydro-4H-pyrazino[2,1-a]isoquinolin-4-one (praziquantel, EMBAY 8440, Biltricide) is effective in giving high cure rates in each infection separately, 66% (64 patients) and 77% (94 patients), respectively. The complete clearance of both infections (i.e., no eggs whether dead or alive) 6 months after treatment was 29% (43 patients). The side effects of the drug were minimal and transient, the most common being gastrointestinal ones. The assessment of the objective tolerability by clinical, haematological and biochemical tests showed also that the drug was very safe. It is thus concluded that the drug is a promising useful tool in the control of schistosomiasis in general and the treatment of the individual.

Migrant workers and schistosomiasis in the Gezira, Sudan.

A cross sectional study of schistosomiasis in migrant laboureres in the Sudan Gezira is described. The people examined were of two ethnic groups: (i) those of local Arabic origin and (ii) those from Western Sudan, West Africa or west of longitude 27 degrees E. These two migrant groups were examined in one area treated with molluscicide and in another that was not. Almost all the schistosome infections were with Schistosoma mansoni, with a prevalence of 57% over-all and up to 89% in particular groups. The prevalence was lower in the treated than in the untreated area, and slightly lower in the Arab nomads than in the others, except that it was markedly lower in females from the West in the treated area. These results are consistent with the known water-contact habits of the two migrant groups. An association was observed between infection and liver and spleen enlargement, but not between infection and other symptoms. The potential importance of migrants in transmitting the infection is discussed.