Cutaneous Leishmaniasis : A Neglected Vector Borne Tropical Disease in Midwestern Region of Nepal

Introduction: Cutaneous Leishmaniasis is a vector borne disease caused by the bite of an infected sandfly. The disease is rare in Nepal with only few cases reported till date. We report the largest collection of patients over six years. Objective: To describe the clinical, epidemiological and pathological aspect of Cutaneous Leishmaniasis in Midwestern region of Nepal Materials and Methods: Thirty-three patients referred to the department of Pathology for fine needle aspiration were diagnosed as Cutaneous leishmaniasis based on detection of Leishmania donovani in the fine needle aspiration smears. Demographic data and clinical details including site, size, and duration of disease onset were recorded on a printed proforma. Statistical analysis was done using SPSS version 16.0 for windows. Results: A total of 33 patients with age ranging from 11 years to 65 years were included in the study. Mean age was 26.5±11.5 years. Most patients were in the age group 21-40 years. Male: Female ratio was 1.7:1. Mean duration of disease was 5.3±4.4 months. Thirty patients had single lesion. Lesions were either of plaque type (84.9 %) or papulonodular type (15.1%). Conclusion: Cutaneous leishmaniasis is uncommon in Nepal. So, it is often neglected. It is in an increasing trend. Cutaneous leishmaniasis should be included in the differential diagnosis of a non-healing ulcer.


Introduction
C utaneous leishmaniasis (CL) is the most common form of Leishmaniasis. 1 According to the data of World Health Organiza on, India is endemic for cutaneous leishmaniasis. 2 Though visceral leishmaniasis is common in Terai region; cutaneous leishmaniasis is rare in Nepal.4][5][6][7] It is a parasi c disease transmi ed by sandfl y infected with the protozoa Leishmania.Cutaneous leishmaniasis occurs at the site of inocula on.The incuba on period between the bite of infected sandfl y to development of lesion is 2 weeks to 6 months.It is caused by L. tropica, L. major, and L. aethiopica in the old world and by L. Mexicana, L. amazonensis, and L. braziliensis in the New World. 8Clinical manifesta on range from painless spontaneously healing nodulo-ulcera ve lesion to disfi guring ulcers.Healed lesions o en leave residual atrophic scars. 9 Nepal, the fi rst case of cutaneous leishmaniasis was reported in 2006 by Pandey BD et al. 2 Since then the prevalence of the disease is slowly rising.Here we report a largest collec on of cases over the six years period.The aim of the study was to describe the clinical, epidemiological and pathological aspect of CL in Mid-western Nepal.

Materials and Methods
The present study includes pa ents with nonhealing ulcer referred from Surgery, ENT and Medicine departments and also clinically suspected cases of cutaneous leishmaniasis who came to the Dermatology department of Nepalgunj Medical College and Teaching Hospital, Banke during the period of six years; from January 2012 to November 2017.All the pa ents were referred to the department of Pathology for impression smear/fi ne needle aspira on (FNA).
Demographic data and clinical details including site, size, and dura on of disease onset were recorded on a printed proforma.Each pa ent was asked about travel history outside the country.
Fine needle aspira on was done from all lesions from the base of the ulcer using 23-gauge needle and 10ml syringe for suc oning.Skin scrapping and slit skin smears were not made in any of our cases.The air-dried smears were then stained with Giemsa stain.Two of our cases came to our hospital with non-healing surgical wound, for which excision of the primary wound was done outside.These two cases were subjected to FNA and biopsy followed by histopathology.Diagnosis of CL was made based on detec on of Leishmania donovani (LD) body in the smears.All of our pa ents were posi ve for LD bodies.SPSS version 16 for windows was used for sta s cal analysis.
Approval le er from the ins tu onal review board was obtained before star ng the study.

Results
This prospec ve study is a review of pa ents with cutaneous Leishmaniasis diagnosed by fi ne needle aspira on cytology and histopathology over the period of 6 years.A total of 33 pa ents ranging from 11 years to 65 years with mean age of 26.5±11.5 years were diagnosed during the six years period.Most of the pa ents were in the 21-40 years age group (Table 1).There were 21 male pa ents and 12 female pa ents.Male: female ra o was 1.7:1.Most of the pa ents were from Kalikot (Table 2).
Dura on of the disease at the me of presenta on ranged from one month to 24 months with mean dura on of 5.3±4.4months.None of the pa ents could give history of insect bite or trauma.Three pa ents gave history of travel to India in the preceding 2 years.Rest of the pa ents denied history of travel in the preceding 2 years.
Thirty pa ents (90.9%) had single lesion (Figure 2).Among the remaining pa ents, lesions were mul ple.Among the single lesions most of them were in the face (Table 3).Among the facial lesions the lesions were concentrated over the nose, angle of mouth, lips, cheeks, forehead, chin and submandibular region.Submental lymphadenopathies were seen in two pa ents with lower lip involvement.In three pa ents (9.0%) the lesions were either on the shoulder or dorsum of hand or forearm.
Lesions were either of plaque type (85%) or papulonodular type (15.1%).Red, ulcerated plaque was more commonly seen as compared to non-ulcerated plaque.Eighteen pa ents had ulcerated plaque.
All the pa ents denied history of fever and had no signs of systemic involvement on examina on.

Discussion
Cutaneous leishmaniasis is a signifi cant public health problem transmi ed by sandfl y.The disease is endemic in places with dry and hot environment, which is favorable for breeding of sandfl y.Till date only few cases have been reported in Nepal.
In the present study, highest number of pa ents were in the 21-40 years age group, which is similar to study by Sharma NL et al. 10 In contrast, Gurel MS et al found a higher incidence in pa ents of 5-9 years age group. 11imilarly, some authors have found a higher incidence of cutaneous leishmaniasis in the 10-19 years age group. 9,12,13The number of pa ents decreased with advancing age which may be due to acquired immunity.
In the present study, the disease was more common in males with male to female ra o of 1.7:1.This fi nding is similar to studies done by Aara N et al 9 and Srivastava et al. 13 In contrast, other authors have found a higher incidence of disease in females. 11,12In Nepal, females are mostly involved in household works and males are involved in outdoor works.This may have predisposed the males to the bite of sand fl y.
In our study, mean dura on of disease from the onset of lesion to diagnosis was 5.3±4.4months.Aara N et al 9 reported 3.7 months and Sharma et al 10 reported 6.9 months.Delay in diagnosis was due to misdiagnosis due to its rarity in our part.Moreover, there was delay in the presenta on as the pa ents had to travel from the remote place to seek for medical advice.
Most of our pa ents had single lesion which is similar to the fi nding of Aara N et al 9 and Galgamuwa LS et al. 14 In our study, lesions were more common in face.
][13] Upper limb involvement was common in the studies conducted by other authors. 9,14,15These fi nding suggest that exposed part of body like face and limbs are more prone to bite of sand fl y.
Ulcerated plaque was the c ommonest type of lesion in our study.Ulcerated plaque was also reported as the most frequent lesion by Aara N et al. 9 In contrast to this, Sharma NL et al reported ulcerated nodules as the most frequent lesion. 10 our study, laboratory diagnosis of cutaneous leishmaniasis was performed by aspira on cytology alone which was diff erent from other studies and English literature which recommends scraping, slit skin smear, biopsy, culture and PCR.
FNA is not a popular method of diagnosis of nonhealing ulcer.Aspira on of skin lesion have been reported in one study in Nepal by Jha A et al. 16 FNAC is less me consuming, non-scar forming, easy to repeat, cheap, and confi rmatory technique for the demonstra on of parasite.We can also see other features like epithelioid cell granulomas, lymphocytes and plasma cells along with intra and extracellular organisms of 2 to 4-micron size.
All our cases were posi ve for LD bodies.Thus, invasive procedures like biopsy and expensive PCR techniques were not done.

Conclusion
Cutaneous leishmaniasis is in increasing trend in Nepal.Implementa on of vector control program along with health educa on may help in the control of infec on.Due to the increasing clinical diversity of the disease, CL should be suspected as a diff eren al diagnosis when dealing with chronic non-healing ulcer.
Financial disclosure: None.Confl icts of interest to disclosure: None declared.

Figure 2 :
Figure 2: Erythematous plaque with crust in lower lip area involving mentolabial sulcus.

Figure 3 :
Figure 3: Giemsa stain, 100 x Photomicrograph showing macrophage packed with numerous amastogotes of Leishmania, approx. 2 to 4-micron size.Plasma cell at the bo om.Extracellular LD bodies are also seen at the top amongst other infl ammatory cells.

Figure 4 :
Figure 4: Giemsa stain, 40 x Photomicrograph showing well-formed epithelioid cell granuloma, macrophage with numerous intracellular LD bodies and mixed acute and chronic cell infi ltrates in the background.

Figure 1 :
Figure 1: Non healing ulcer in the upper, lower lip as well as lateral aspect of the right upper arm.

Table 1 :
Distribu on of pa ents according to age group.

Table 2 :
Distribu on of pa ents according to district.

Table 3 :
Distribu on of the lesions in pa ents with solitary lesion.
All the pa ents were posi ve for LD bodies in smears.NJDVL.Vol 16, No.1, 2018