Indian Journal of Paediatric Dermatology

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 19  |  Issue : 1  |  Page : 37--39

Cutaneous leishmaniasis in children: A case series


Mrinal Gupta 
 Treatwell Skin Centre, Jammu, Jammu and Kashmir, India

Correspondence Address:
Mrinal Gupta
Treatwell Skin Centre, Canal Road, Jammu - 180 019, Jammu and Kashmir
India

Abstract

Background: Cutaneous leishmaniasis (CL) is a protozoal disease usually caused by Leishmania major and Leishmania tropica and transmitted by the bite of a sandfly. It is usually characterized by a single, polymorphous lesion located in an uncovered area. Aims: This study aimed to evaluate the clinico-epidemiological characteristics of CL among children. Materials and Methods: It was a retro-prospective study carried out over a period of 18 months in our center, in which the clinico-epidemiological features of children presenting with CL were assessed. Results: A total of 10 children (male:female - 7:3) were included in the study with the age range of 1–15 years, with a mean age of 8.8 years. Face was the most commonly affected site (n = 8), followed by neck and hands (1 each), and nodulo-ulcerative was the most common clinical type seen in nine patients. Skin smears for Leishman–Donovan (LD) bodies were positive in five patients while the skin biopsy, which was done in four cases, showed the presence of LD bodies in only one patient. Conclusion: CL is a common presentation among children, especially in the endemic areas, and the clinical features are similar to the adult onset disease.



How to cite this article:
Gupta M. Cutaneous leishmaniasis in children: A case series.Indian J Paediatr Dermatol 2018;19:37-39


How to cite this URL:
Gupta M. Cutaneous leishmaniasis in children: A case series. Indian J Paediatr Dermatol [serial online] 2018 [cited 2019 Dec 6 ];19:37-39
Available from: http://www.ijpd.in/text.asp?2018/19/1/37/216942


Full Text

 Introduction



Leishmaniasis is a parasitic disease caused by Leishmania organism, transmitted by the bite of infected sandfly. Depending on the infecting Leishmania species and host immunocompetence, there are cutaneous, mucocutaneous, and visceral forms of the disease.[1] It has been estimated that 350 million people are at a risk of leishmaniasis and the disease, in its various forms, affects at least 12 million people worldwide, with 1.5–2 million new cases per year.[2] In India, indigenous cases of cutaneous leishmaniasis (CL) are mainly confined to hot, dry North-West Thar Desert of Rajasthan, in certain regions of Uttaranchal, Himachal Pradesh, and Jammu and Kashmir. A large number of CL cases are seen in childhood, and in epidemiological studies, it has been shown that children are at greater risk than adults.[3] In this study, we examined the epidemiological and clinical characteristics of pediatric patients with CL over an 18-month period in the Jammu region.

 Materials and Methods



It was a retro-prospective study carried out over a period of 18 months in our center, in which ten children presenting with CL were assessed. A detailed history was taken including the epidemiological data; onset and duration of skin lesion(s), history of associated itching or pain, history of sleeping outdoors, insect bite, house design, and history of a similar illness in the family or neighborhood were recorded on predesigned pro formas. After obtaining informed consent, each patient was subjected to general physical, systemic, cutaneous, and mucosal examination. The clinical diagnosis of CL was made using the clinical criteria proposed by Bari and Rahman and this was further confirmed, whenever possible, by the demonstration of Leishman–Donovan (LD) bodies in Leishman-stained slit skin smears and hematoxylin and eosin-stained skin biopsy sections.[4] Institutional Ethical committee permission was obtained.

 Results



A total of ten (7 males and 3 females) children with CL were included in the study with the age range of 1–15 years (mean: 8.8 years). The total number of lesions was 12, with eight patients showing a single lesion and two lesions each in two patients. Face was the most common site of involvement, being involved in eight patients. Over the face, cheeks were involved in four cases, nose in two, and eyelid and lips in one patient each. Neck (n = 1) and hands (n = 1) were the other involved sites [Figure 1]. The most common clinical variant was nodulo-ulcerative (n = 9) followed by erythematous, edematous plaque in one patient. The duration of skin lesions varied from 1 month to 12 months. Most of our patients lived in mud houses (n = 8), and a history of sleeping outdoors was noted in four patients. Two patients had a history of similar lesions in the family or in the neighborhood.{Figure 1}

Skin smears for LD bodies were positive in five patients while the skin biopsy, which was done in four cases, showed the presence of LD bodies in only one patient [Figure 2]. Culture for Leishmania could not be done due to unavailability in our setup.{Figure 2}

Out of the ten patients, nine were given weekly intralesional sodium stibogluconate (SSG) for durations ranging from 4 to 8 weeks depending on the clinical response while the patient with eyelid lesion was administered daily intramuscular SSG at a dose of 20 mg/kg/day for 3 weeks.

The clinico-epidemiological characteristics of the patients are shown in [Table 1].{Table 1}

 Discussion



CL is a common parasitic disease with variable clinical manifestations, mostly involving the exposed sites with face, neck, and arms being the most commonly involved. The diverse clinical spectrum of CL results from the complex interaction of a number of factors such as the type and duration of clinical lesions, strain of organism, geographic location, parasitic load, disease reservoir, and host immunocompetence. Lesions caused by CL generally start as a small papule or may occur in a papulo-nodular form which, if untreated, increase in diameter and may ulcerate.[5]

Studies have shown a high incidence rate of CL among pediatric population. The most likely reason for the greater incidence in children is that children are exposed to the parasite at an early age, and as they have not been exposed to leishmaniasis, they lack immunity to CL.[3] Diagnosis of CL among children is often difficult and the patients may be misdiagnosed as impetigo or folliculitis by the practitioners, thereby leading to delayed treatment, which may lead to the spread of disease and scarring. The diagnosis of CL has to be suspected in children presenting with chronic, nodular, or ulcerated lesions on the face or exposed sites.

In endemic areas, the clinical diagnosis is not difficult. Usually, this is best achieved by performing a smear of the material from the lesion and staining it with Wright or Giemsa stain which may reveal the presence of LD bodies. Demonstration of parasite in direct smears remains the easiest and the most specific method of diagnosis. The smears are positive in 50%–70% of the cases, depending on the age of lesions; younger lesions being more likely to yield the parasite. Histopathological examination of the lesion may also reveal LD bodies, but the organisms are scarce and difficult to identify in sections stained with H and E stain which may be due to repeated processing of biopsy specimens with dehydrating solutions. Culture of the material in Novy–MacNeal–Nicolle medium or polymerase chain reaction may also be done for the confirmation of the diagnosis.[6] Modern methods for the diagnosis of leishmaniasis include immunofluorescence, use of monoclonal antibodies, DNA probes, polymerase chain reaction, and electron microscopic studies.

Numerous treatment modalities have been used for the management of CL. The more effective treatment is with pentavalent antimonial compounds or SSG, and the dosage recommended by the World Health Organization is 20 mg/kg/day over 3 weeks.[2] However, intralesional treatment may be considered as a preferential form of treatment for CL among pediatric population so as to avoid the toxicity associated with systemic administration of antimonials.[3] Other modalities of treatment include 20% paromomycin ointment, cryotherapy, liposomal amphotericin B, and oral antifungals.[2],[7]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Bari AU, Rahman SB. Many faces of cutaneous leishmaniasis. Indian J Dermatol Venereol Leprol 2008;74:23-7.
2Jafari AK, Akhyani M, Valikhani M, Ghodsi ZS, Barikbin B, Toosi S. Bilateral cutaneous leishmaniasis of upper eyelids: A case report. Dermatol Online J 2006;12:20.
3Aksoy M, Doni N, Ozkul HU, Yesilova Y, Ardic N, Yesilova A, et al. Pediatric cutaneous leishmaniasis in an endemic region in Turkey: A retrospective analysis of 8786 cases during 1998-2014. PLoS Negl Trop Dis 2016;10:e0004835.
4Ul Bari A, ber Rahman S. Correlation of clinical, histopathological, and microbiological findings in 60 cases of cutaneous leishmaniasis. Indian J Dermatol Venereol Leprol 2006;72:28-32.
5Ul Bari A, Raza N. Lupoid cutaneous leishmaniasis: A report of 16 cases. Indian J Dermatol Venereol Leprol 2010;76:85.
6Sharma RC, Mahajan VK, Sharma NL, Sharma A. A new focus of cutaneous leishmaniasis in Himachal Pradesh (India). Indian J Dermatol Venereol Leprol 2003;69:170-2.
7Veraldi S, Bottini S, Currò N, Gianotti R. Leishmaniasis of the eyelid mimicking an infundibular cyst and review of the literature on ocular leishmaniasis. Int J Infect Dis 2010;14 Suppl 3:e230-2.