NASALINVOL VEMENTIN CUT ANEOUS LEISHMANIASIS

7/28/2019 NASALINVOL VEMENTIN CUT ANEOUS LEISHMANIASIS

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ABSTRACT

Objective:To determine the frequency of nasal involvement in cutaneous leishmaniasis and to studydemographic and clinical pattern of disease involving nose as well as nasal mucosa.

Materi al and M ethods:Patients with cutaneous leishmaniasis presented to leishmaniasis clinic situated inthe Basic Health Unit for Afghan refugees at Sarai Gambeela, District Lakki Marwat from January 1, 2009to December 31, 2009 were registered. The patients were diagnosed clinically and confirmed by laboratorydemonstration of parasite in a giemsa stained smear prepared from the lesion. Those having lesions

primar ily on nose, irrespective of age and gender were included in the study. All those cases with primar ylesion elsewhere over face and seconda rily involving nose (creeping lesion) were excluded. All importantclinical details were recorded on a specially designed proforma and patients were given a registration cardfor the purpose of treatment and follow up visits.

Results:Sixty seven out of 682 (9.82%) cases of nasal leishmanisis were encountered. Male to female ratiowas 2:1. Forty nine (73.13%) had solitary lesions and among these fourty four (65.67%) had lesionslimited to their nose. Wet type cutaneous leishmaniasis was seen in 19 (28.36) cases. Seventy three percentof sufferers were less than 30 years of age.

Conclusion:Cutaneous leishmaniasis is endemic in Distt. Lakki Marwat. Nose was a common site ofinvolvement. In endemic areas, it should be included in the differential diagnosis of nasal lesions.

Key words:Cutaneous leishmaniasis (CL), Nose.

Old world and new world CL encompass aINTRODUCTIONdiversity of clinical manifestations usually

Cutaneous leishmaniasis (CL) is a groupevolving from papules to nodules, which then

of parasitic diseases transmitted by sand fly vectorulcerate centrally to leave a raised indurated

13,4and affecting 15 million people worldwide . Most border (Fig. 1). The mucosal form usually occurs

cases of localized CL come from Afghanistan, after an initial cutaneous infection and maySaudi Arabia, Syria, Iran and America. Pakistan progress to dest ruct ion of mucosa and even

5,6also has a considerable number of leishmaniasis cartilage. . CL typically occurs on exposed partscases, both cutaneous and visceral. Prevalence has of the body and nose being projected and non

been estimated at 2.7% in the northwestern part of motile part of the face is most vulnerable for sandthe country. Incidence in Pakistan has been fly bite. Nasal mucosa and nasopharynx areestimated at 4.6 cases /1000 persons/year over the involved as a part of mucocutaneous leishmaniasis.

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Lesions in the mucocutaneous stage range fromlast 10 years . Humans and a wide range of s imple oedema to l a rge d i s f i gur ing and vertebrates serve as reservoirs of infection. Threenoduloulcerative plaques that can lead to nasaldominant clinical forms of the disease are

7,8,9obstruction, epistaxis and septal perforation .recognized; cutaneous, mucosal and visceral

3,4leishmsnisis . In Khyber Pakhtunkhwa the disease With the increase in international travel,

11 23is reported from district Dir , Kohat and Afghan immigration, overseas military exercises and HIVrefugee settlements. In Afghanistan and Pakistan infection, CL is becoming more prevalenttwo leishmania species; L-tropica causing dry type throughout the world. Over the past few years,of lesions and L-major producing wet type of spread of CL has been reported from all over the

24lesions are mainly seen . Pakistan. This includes discovering of new foci of

ORIGIN AL ARTICLE

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NASAL INVOLVEMENT IN CUTANEOUS LEISHMANIASIS

District Head Quarter Hospital Lakki Marwat,Department of Orthopaedics and Dermatology, PGMI Peshawar - Pakistan

Muhammad Ismail Khan, Mumtaz Muhammad, Waliullah khan, Nadir Khan,Sahibzada Mehmood Noor


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10,11,12CL as well as increased number of cases being

13-17reported from the known endemic regions .

The Population of District Lakki Marwatcomprises of Marwat and Bettani tribes as mainethnic origins. Afghan refugees are also living inthousands dispersed throughout the district. DuringSoviet occupation of Afghanistan, millions ofAfghan refugees came to Pakistan. Like otherareas of Khyber Pakhtunkhwa a refugee camp wasestablished at Sarai Gambeela Distt. LakkiMarwat. Hundreds of Afghan refugee families arestill living here. These war related population /movements and environmental destruction havecaused a large increase in the CL prevalence inlocal population.

Due to increase in the prevalence ofcutaneous leishmaniasis in the Afghan refugeesand local population, a leishmaniasis clinic wasestablished in 1997 at BHU for Afghan refugees atAfghan refugee camp Sarai Gambeela, Distt. LakkiMarwat. Patients are diagnosed on the basis ofsmear for parasites and treated with pentavalentantimonial compounds free of cost. ProjectDirectorate Health provides health facilities toAfghan refugees living in Afghan refugee camp at

and eighty two patients with clinically suspectedSarai Gambeela.

leishmaniasis presenting to the leishmaniasis clinicof BHU Sarai Gambeela Lakki Marwat wereThe present study was aimed to determineregistered. Diagnosis was made on the basis ofthe frequency of nasal leishmaniasis and to

cl inical characterist ics of the lesions anddescribe the demographic and clinical pattern ofpatients with nasal leishmaniasis presenting to l a b o r a t o r y d e m o n s t r a t i o n o f l e i s h m a n i aleishmaniasis clinic at BHU Sarai Gambeela, Distt: trophozoites bodies in a Giemsa-stained smearLakki Marwat. from the edge of the lesion. Smear examination is

the earliest and sole method to confirm the clinicalMATERIAL AND METHODS diagnosis in an endemic area. In our study only

smear positive cases were included in the study.This study was carr ied out in theThe smear was processed and examined byleishmaniasis clinic at BHU Sarai Gambeela for

pa tholog is t posted at Dist rict Head Quar tersAfghan refugees District Lakki Marwat fromHospital Lakki as per following procedure.January to December 2009 (Fig. 2). Six hundred

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Figure 1: Distribution of Old world and New World CL

Figure 2:

Distt. Lakki Marwat

Map of Pakistan showing


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Specimen from the lesion is put on a slide All the cases were registered and a card was

and is allowed to dry. It is fixed with methanol issued for the purpose of treatment and follow up.Pat ients were t rea ted according to WHOand is again dried in air. I ml of Giemsa stainrecommendations with Sodium Stibogluconate.stock solution is diluted in 10 ml of distilled

water. This diluted giemsa stain is poured on theRESULTSslide. After 15-30 minutes the slide is washed with

tap water and is dried in the air. The slide is then A Total of six hundred and eighty twoexamined under microscope.

pat ients were registered as cases of CL fromJanuary to December 2009. Out of those, 67All those patients having lesions solely or(9.82%) were found to have nasal cutaneous orprimarily on nose were enrolled as cases of nasalmucocutaneous lesions. There were 44 (65.67%)CL and included in the study after obtainingmales and 23 (34.33%) females. Although diseaseinformed consent from each patient. Thosewas prevalent in all age groups but it was morepatients having isolated lesions else where on the

nd rd common in 2 (31.34%) and 3 decade (25.37%)body as well as on the nose were also included.of life. The duration of lesions ranged from 4All those patients were excluded from the studyw e e k s t o 1 2 w e e k s . F a m i l y h i s t o r y o f who either refused to participate or they had skinleishmaniasis was positive in 13 (19.40%) patients.lesions that looked like bacterial infectionsOnly 17 (25.37%) patients had knowledge of the(furuncles, impetigo and erythema) and resolveddisease while other 11 (16.40%) patients gave

after a short course of antibiotics. Clinical featureshistory of using protective measures like nets and

including age, gender, nationality, duration of themosquito repellant oils.

lesion, family history, use of protective measuresand awareness of the disease were recorded on a Majority of the patients were localbelonging to Marwat tribe (46.26%) and Betanniregister. The clinical patterns of the lesions were

tribe (28.35%) whereas 17 (25.37%) patients wererecorded in all cases and subsequently categorized.

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Table 1: Demographic features of patients with nasalcutaneous leishamaniasis (n=67)

ParametersNumber of

patientsPercentage

GenderMaleFemale

4423

65.67%34.33 %

Age groups(years)0-1011-20

21-3031-4041-5051-60

1121

17110403

16.41%31.34%

25.37%16.41%5.97%4.47%

Ethnic OriginMarwatBetanniMahajirs

311917

46.26%28.35)%

25.37%

Family HistoryPositive

Negative1354

9.40%

80.60%

Use of protective measuresUsing

Not using1156

16.40%83.60%

Awareness of the diseaseYes

No1750

25.37%74.63%

Duration of the lesions (weeks)0- 45-8> 8

212709

31.34%40.29%13.43%

Geographical originUrbanRural

0760

10.44%89.55%


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Afghan refugees. It was noted in our study that the weeks. Nasal affliction could possibly be due todisease was more common in rural population the fact that nose is the most projected part of face(89.55%) as compared to urban (10.44%) and its inability to avoid sand fly bite by moving

population. Wet type of leishmaniasis was seen in it away and is easily accessible site for its bite. In

our study, both types of cutaneous leishmaniasis48 (71.64%) patients while dry type was noted inwere seen, although wet type of lesions were more19 (28.36%) patients. Forty nine (73.13%) patientscommon i.e; 71.64%. This is also supported byhad single lesion and among these, forty four

22(65.67%) had lesions limited to their nose. In 11 Rab et al . Other studies from Sadda Kurram

13 23(16.14%) patients, nasal lesions also extended to Agency and from Multan reported dry type ofthe adjoining areas i.e. cheeks and upper lip. In 10 lesions. The occurrence of both types of cutaneous

leishmaniasis may be due to presence of L-major(14.92%) patients isolated lesions were found onas well as L-tropica in this region.the nose as well as other parts of the body i.e.

legs, trunk and hands. Three (4.47%) patients hadAlmost all the patients were from Distt.

mucocutaneous type of lesions i.e. involving nasalLakki Marwat which signifies that the disease is

mucosa in addition to cutaneous affliction.endemic. It was noted in our study that the diseasewas more common in rural population as comparedDISCUSSIONto urban population as 89.55% and 10.45%. Due to

Outbreaks of CL have been reported from lack of facilities and trained personal, the diseaseseveral areas of the world including Pakistan. Such is under diagnosed, therefore a high clinicalout breaks have largely been reported from suspicion should always be observed whilenorthern areas of Pakistan especially with the encountering various lesions on nose that do not

11-14arrival of Afghan refugees . Mostly the reason respond to appropriate conventional therapies.has been the settlement of a large population in the

CONCLUSION18natural habitat of Sand fly . The present out breakcan be linked to large-scale influx of Afghan Cutaneous leishmaniasis is endemic inrefugees across the border. Initially the disease was Distt. Lakki Marwat where thousands of Afghanlocalized to Afghan refugees but gradually it refugees are living. Nasal leishmaniasis is a

common form of CL. Dermatologists andinvolved the local population, which was non-otolaryngologists should keep it in mind whenimmune to the disease as reported from other parts

19 examining lesions of the nose especially inof country .endemic areas, as early diagnosis and prompt

In literature many isolated case reports of treatment significantly reduce morbidity related to7,8,20,21

primary nasal involvement in CL are avai lable the disease.but there has been only one case series describingvarious clinical patterns of nasal involvement by REFRENCES

24Bari AU et al . In our study frequency of nasalinvolvement in CL is 9.82% but the study fromMuzzafarabad shows 29% nasal involvement in

24CL . In our study it was noted that the commonvictims were children, adolescents and youngadults. The duration of lesions ranged from 4 to 12

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2. Kolaczinsk i J , Brooker S, Reyburn H ,Rowland M. Epidemiology of anthroponotic

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Table 2: Var ious clinical patterns of nasal cutaneous leishmaniasis (n=67)

ParametersNumber of

PatientsPercentage

Clinical type of the lesion

Wet

Dry

48

19

71.64%

28.36%

No of Lesion

12

>2

491305

73.13%19.40%

7.50%

Site of Lesions

Nose only (Solitary lesion)

Nose and other areas of face

Nose and other parts of body other than face

Mucocutaneous

44

11

10

03

65.67%

16.14%

4.92%

4.97%


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Address for Correspondence:Dr. Muhammad IsmailENT SurgeonMarwat General HospitalLakki Marwat - Pakistan

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NASALINVOL VEMENTIN CUT ANEOUS LEISHMANIASIS

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