Case Report: A Single-Center Case Series on Skin Manifestations of Leishmaniasis from a Non-Endemic State in Southern India

ABSTRACT

Leishmaniasis is endemic in the Indian subcontinent with predominance of visceral leishmaniasis (VL) due to Leishmania donovani. Cutaneous leishmaniasis (CL) is uncommon, and mucocutaneous leishmaniasis (MCL) is rarely reported in this region. Recent reports reveal a changing epidemiology and atypical manifestations. A retrospective study of 52 suspected cases with cutaneous and mucosal involvement seen from January 2008 to December 2018 in a tertiary care setting in a non-endemic state in southern India is reported. Twelve patients were confirmed to have leishmaniasis; seven had MCL, two had CL, and three had post-kala-azar dermal leishmaniasis (PKDL). All cases were male, with a median age of 41.5 years (interquartile range, 30–55.5 years), and the median duration of the disease was 6 years (interquartile range, 1–9.5 years). Patients with MCL had mucosal involvement including destructive ulcero-proliferative lesions due to delayed diagnosis; none had a history of travel to countries endemic for MCL and all were attributable to L. donovani species. On the other hand, Leishmania major which was the causative species in both CL patients was associated with travel to the Middle East. Patients with PKDL presented with multiple plaques and hypopigmented patches; one had concomitant VL and all were from endemic areas. Hitherto uncommon MCL, caused by potentially atypical variants of L. donovani, has emerged as a new manifestation of leishmaniasis in this region. A high index of suspicion based on lesions seen and history of travel combined with PCR-based diagnostics are required to confirm diagnosis for the various skin manifestations of leishmaniasis.

INTRODUCTION

Leishmaniasis is a widely prevalent neglected tropical disease with atypical clinical presentations and changes in tropism in different geographical locations emerging as a new challenge. More than 600,000 to one million new cases of cutaneous leishmaniasis (CL) have been estimated to occur worldwide annually caused by a range of Leishmania spp. Cutaneous leishmaniasis is less common in India and has been reported from the states of Rajasthan, Punjab, Assam, Haryana, Delhi, Jammu and Kashmir, and recently from Kerala and Himachal Pradesh.¹ In Kerala and Himachal Pradesh, atypical variants of Leishmania donovani have been identified as the causative agent of CL, whereas a recent study in Bikaner, Rajasthan, identified Leishmania tropica.^2,3 Approximately 90% of the global burden of mucocutaneous leishmaniasis (MCL) has been reported from Bolivia, Brazil, and Peru caused by a range of new world Leishmania species.⁴ Mucocutaneous leishmaniasis is rare in the Indian subcontinent with a few reports from Bihar, Uttarakhand, and Bhutan attributed to L. donovani.^5–7 Visceral leishmaniasis (VL) or Kala-azar, on the other hand, is endemic in India. An estimated 50,000–90,000 new cases of VL occur worldwide each year.⁸ Most new cases of VL in India are reported from Bihar, West Bengal, Jharkhand, and Uttar Pradesh which are hyperendemic.^9,10 Upto 15% of cases with apparent cure of VL in India have been reported to develop cutaneous sequelae called post-kala-azar dermal leishmaniasis (PKDL).¹¹

In this case series, we have aimed to describe leishmaniasis cases with skin manifestations seen over a decade (January 2008–December 2018) at a dermatology unit in a large tertiary care hospital located in the non-endemic state of Tamil Nadu in southern India. In addition to catering to a large number of local patients (40% of hospital admissions), the hospital draws patients from all over India, including Leishmania-endemic states of West Bengal (17%), Bihar (2%), and Jharkhand (8%). Approximately 11% of admissions at the hospital in 2018 were from neighboring countries including Bangladesh, Nepal, and Bhutan.¹² Although this case series presents data collected at a single hospital, the wide geographic range of the patient population could provide insight on the species associated with cutaneous manifestations of leishmaniasis in the south Asian subcontinent.

All patients with suspected CL, MCL, or PKDL with lesions as defined^13–16 in Supplemental File 1 seen during the study period were reviewed. Patients with Leishmania culture and/or tissue PCR positive for Leishmania spp. were then included in this series. A chart review of confirmed cases collected data on demographic details including travel history, clinical features including type and extent of cutaneous and mucosal involvement, and any associated systemic involvement and treatment given, response, and any follow-up outcomes in an Excel spreadsheet. Laboratory data on HIV status, histopathological findings, rk39 dipstick, Leishmania culture on biphasic media, Leishmania PCR (Internal Transcribed Spacer [ITS] 1) followed by RFLP or Sanger sequencing, and L. donovani–specific PCR (Leishmania donovani [LD] 1) were included. This retrospective study was approved by the Institutional Review Board of Christian Medical College, Vellore, and all patient information was kept confidential.

CASE SERIES

During the study period, from January 2008 to December 2018, 52 patients were suspected to have CL, MCL, or PKDL, of which 12 were confirmed to have leishmaniasis (Table 1). All cases were males, with a median age of 41.5 years (IQR, 30–55.5 years). Previous studies have shown gender-associated differences in leishmaniasis, but a gender bias (41 of 52 suspected patients were males) in seeking healthcare cannot be ruled out.¹⁷ The final diagnosis of the remaining 40 cases included other infective etiology such as tuberculosis, deep fungal and bacterial infections (50%), malignancies (32.5%), and inflammatory and autoimmune diseases (17.5%) (Supplemental File 2).

Table 1.

Case series of leishmaniasis patients with skin manifestations (n = 12)

Case	Age (years)	Place	Duration (years)	Presentation	Site of lesions	Single/multiple	Localized/disseminated	LD body	NNN culture	rk39	ITS PCR	LD1 PCR	Species	Initial treatment	Cumulative dose of L-amp B (in gms)	Maintenance treatment	Complications of therapy	Follow-up (months)	Outcome of lesions
Cutaneous leishmaniasis
1	53	Tamil Nadu	0.83	Nodule	Lower limbs	Multiple	Localized	–	+	+	+	–	L. major	L-amp B	1.5	Itraconazole	–	2	Improved
2	42	West Bengal	1	Plaque	Back	Multiple	Localized	+	–	+	+	–	L. major	L-amp B	1.1	Fluconazole	–	1	Improved
Mucocutaneous leishmaniasis
3	48	Bhutan	9	Plaque	Centro-facial, palate	Multiple	Localized	–	+	+	+	+	L. donovani	L-amp B	2.5	Itraconazole	Fever and chills	2	Improved
4	41	Bhutan	7	Plaque	Centro-facial, trunk, palate	Multiple	Disseminated	+	+	+	+	+	L. donovani	L-amp B	2.6	Not given	Hypokalemia	1	Improved
5	58	Bhutan	10	Nodule	Diffuse pharyngeal involvement	Single	Localized	–	–	+	+	+	L. donovani	L-amp B	1.3	Not given	Hypokalemia	1	Improved
6	28	Bhutan	5	Ulcer	Diffuse pharyngeal involvement	Single	Localized	–	+	+	+	+	L. donovani	L-amp B	1.2	Not given	Mild renal dysfunction	1	Improved
7	24	Bhutan	0.33	Nodule	Diffuse pharyngeal involvement	Single	Localized	+	+	+	+	+	L. donovani	L-amp B	2.2	Not given	Acute renal failure	36	Improved
8	76	Bihar	3	Nodule	Pharynx and nasal cavity	Single	Localized	–	–	+	+	+	L. donovani	L-amp B	1.2	Not given	–	24	Improved
9	62	Bhutan	40	Ulcer	Nasal cavity, buccal mucosa	Single	Localized	–	–	–	+	+	L. donovani	L-amp B	2.4	Not given	Fever, hypokalemia	7	Improved
Post-kala-azar leishmaniasis
10	13	Bihar	1	Ulcer	Submandibular sinus	Single	Disseminated	+	–	+	+	+	L. donovani	Conventional amp B	0.5	Not given	Anemia	2	Improved
11	32	Bangladesh	12	Patch	Centro-facial, trunk, forearm	Multiple	Disseminated	–	–	+	–	+	L. donovani	L-amp B	1.8	Itraconazole	–	1	Improved
12	33	Bihar	8	Plaque, nodule	Centro-facial, buttocks, nasal mucosa	Multiple	Disseminated	+	+	–	+	+	L. donovani	Itraconazole	–	Lost to follow-up	–	4	–

L. donovani = Leishmania donovani; L. major = Leishmania major. NNN = Novy-MacNeal-Nicolle media

Cutaneous leishmaniasis.

Two patients had CL with varied clinical presentations. One was from a non-endemic state of Tamil Nadu and the other from a VL-endemic state, West Bengal. Both gave a history of travel and work in Saudi Arabia. The first case had disseminated CL with multiple papules, nodules, and ulcers distributed over the lower limbs (Figure 1A), whereas the second case had localized CL with two plaques over the back for a duration of ∼1 year. Histopathological examination revealed chronic granulomatous inflammation with lymphoplasmacytic inflammation and LD bodies. In both cases, the causative species was found to be Leishmania major (Figure 2), which corresponds to the travel history provided. History of travel and residence in an endemic country also led to the diagnostic consideration of CL in these patients. Both patients were treated with liposomal injection amphotericin B and responded well to treatment.

Figure 1.

Cutaneous and mucocutaneous leishmaniasis (MCL) lesions: (A) Cutaneous leishmaniasis with multiple nodulo-ulcerative lesions on the leg, (B) MCL with centro-facial plaques involving the lips, (C) MCL with ulcer involving midline of the nose with destruction of the nasal septum, (D) MCL ulcer post-reconstructive surgery, (E) Post-kala-azar dermal leishmaniasis (PKDL) with dull erythematous plaques over the centro-facial area with mucosa involved, and (F) Post-kala-azar dermal leishmaniasis with hypopigmented patches over the trunk. This figure appears in color at www.ajtmh.org.

Figure 2.

Phylogenetic analysis of ITS1 PCR amplicons of Cutaneous leishmaniasis (CL), Mucocutaneous leishmaniasis (MCL), and post-kala-azar dermal leishmaniasis (PKDL) cases: sequences were trimmed and contigs generated by mapping to reference sequences of Leishmania donovani (AJ634376) and Leishmania major (AJ272383) followed by multiple sequence alignment with reference sequences (MAFFT multiple sequence aligner) and phylogenetic analysis with the Jukes–Cantor substitution model and neighbor joining method with branch support assessed by 1,000 bootstrap replicates (Geneious software v. 6.1, Biomatters Inc., Auckland, NZ, NJ; FigTree v. 1.4.2; http://tree.bio.ed.ac.uk/software/figtree/). ITS1 amplicon sequences were generated and uploaded to GenBank (Accession numbers MW053320–31). This figure appears in color at www.ajtmh.org.

Mucocutaneous leishmaniasis.

Six of the seven cases of MCL seen at our center were from Bhutan, with only one case from Bihar (from Bhagalpur district, 435 km from the border to Bhutan) (Table 1). They presented with lesions over the nasal mucosa, oropharynx, laryngopharyx, or larynx, and the duration of these lesions ranged from 3 months to more than 40 years. Three of these cases have been reported by us and others previously.^6,18 Three cases had dysphagia and hoarseness of voice as their chief complaint. Mucocutaneous leishmaniasis lesions have been documented to present as either subtle or chronic ulcerating mucosal lesions.¹⁹ Clinical presentation varied from erythematous infiltration of the face with palatal involvement (Figure 1B) to severe mutilating, destructive lesion of the palate and nasal septum, especially in long-standing lesions (Figure 1C). Three patients also had proliferative lesions involving the nose, oropharynx, and larynx. Prior treatments in these patients included antituberculosis treatment and dapsone for varying periods with no improvement of their lesions. Four of the patients with only ML had diffuse pharyngeal involvement. Nasopharyngeal stenosis with adherence of the soft palate to the posterior wall of the nasopharynx was seen in three patients. One patient with oropharyngeal, laryngopharyngeal, and laryngeal leishmaniasis developed progressive laryngotracheal stenosis requiring tracheostomy. Histopathological investigations showed granulomatous inflammation with predominantly lymphohistiocytic infiltrate (Figure 3A and B), and three of seven patients showed LD bodies in macrophages. All except one were positive for the anti-rk39 antibody. LD1 PCR identified L. donovani in all the seven patients (Table 1) confirmed by sequencing of ITS1 PCR amplicons (Figure 2). Injection amphotericin B (3–5 mg/kg/day for varying durations) was used for treatment for these patients. Post treatment tissue biopsy from one patient was negative for Leishmania PCR. At a follow-up visit after 3 years, one of the cases had developed sequelae including mucosal scarring, oropharyngeal and nasopharyngeal stenosis, and fibrosis. One of our patients was offered reconstructive surgery after completion of treatment (Figure 1D).

Figure 3.

Histopathological sections of cutaneous and mucocutaneous leishmaniasis skin biopsies: Leishman–Donovan bodies or amastigotes seen in (A and B) macrophages (Hematoxylin and Eosin [H&E] stain ×400) and (C and D) in histiocytes (H&E stain ×400 and H&E stain ×1000). This figure appears in color at www.ajtmh.org.

Post-kala-azar dermal leishmaniasis.

In our study, of the three cases of PKDL caused by L. donovani, two were from Bihar and the third was from Bangladesh. The first patient was a 13-year-old boy coinfected with HIV and presented with a nonhealing ulcer in the submandibular region with features of concomitant VL (with hepatosplenomegaly and bone marrow infiltration positive for Leishmania). Histopathological examination showed granulomatous inflammation with LD bodies (Figure 3C and D). The second case presented with erythematous papules and plaques over the centro-facial area with involvement of the nose and chin, glabella, and left malar area, 11 years after VL (Figure 1E), and the third case had hypopigmented patch over the trunk, forearm, and buttocks with infiltration of the face and earlobes (Figure 1F). There was no organomegaly in either case. Histopathology from the non-HIV patients showed lymphohistiocytic infiltrate and LD bodies. Anti-rK39 antibody was negative in one (who had prior treatment) and positive in the other. The 13-year-old child received conventional amphotericin B deoxycholate 1 mg/kg for 21 days, whereas the second case (received 15 doses of stibogluconate previously with 75% improvement) was unable to afford amphotericin; hence, he was treated with itraconazole. Although miltefosine (100 mg/day, 12 weeks) is the first-line therapeutic regime for treatment of PKDL in India,²⁰ because of unavailability at that time, the third patient was given liposomal amphotericin B at a dose of 5 mg/kg.

DISCUSSION

We have described a series of varied cutaneous manifestations of leishmaniasis seen at a dermatology unit in a tertiary care center in southern India. Increasingly, travel of both skilled and unskilled workers from this region to other endemic areas in the Middle East has led to infection with non-endemic species, which requires a high index of suspicion.^21,22 Our patients with CL had a history of travel to endemic areas, providing a clue to the diagnosis, but differentials ranging from subcutaneous and deep mycosis, cutaneous tuberculosis, lymphoma, and pseudo-lymphoma should be considered.²³ Most patients presented with a prolonged duration of symptoms, and incorrect or delayed diagnosis and treatment, highlighting the need for awareness of various cutaneous presentations of this neglected tropical disease. This is especially distressing in MCL which is known to persist for years, causing destructive lesions of palate and nasal cartilage. Although thought to be rare in the Indian subcontinent, our series indicates that clinicians, even in non-endemic areas, should consider leishmaniasis in the differential of chronic mucocutaneous ulcerative lesions so that early treatment can be instituted to prevent the severe mutilating complications seen. As L. donovani was identified in all seven MCL cases, it is possible that the mucocutaneous involvement was a form of PKDL with mucosal involvement; however, none of our patients gave a history of VL in the past, and destructive mucosal lesions are not usually seen in PKDL. Interestingly, all but one of our patients hailed from Bhutan, but during this same period, there were only sporadic reports of VL and no cases of PKDL or MCL reported from the country. Reports from this period included 19 cases of VL detected in village surveys in 2011²⁴ and only four cases of VL reported from 2014 to 2018.²⁵ Both the village-based surveys and our case series suggest that a more active case finding approach and surveys may be required to detect the true burden of VL in Bhutan as well as the atypical presentations seen. Further molecular analysis of these clinical isolates to determine whether this is an atypical, emerging L. donovani variant causing MCL using whole genome sequencing or multi-locus microsatellite typing is required. Diffuse CL or PKDL can often be mistaken for lepromatous leprosy as the latter is also endemic in India.^26,27 The interplay between leishmanial infections with immunosuppression and HIV also needs to be considered as it can lead to atypical cutaneous presentations.²⁸ Visceral involvement remains a risk in these patients, reiterating the importance of investigating for concomitant VL.¹⁹

There may be understudied and under-recognized foci of leishmaniasis with atypical variants and presentations in the subcontinent as recently reported from Kerala and Sri Lanka.^29,30 Reports of CL and MCL from newer and expanding endemic sites in the Indian subcontinent along with a range of associated species reported demonstrate an increased need for awareness among clinicians and improved laboratory capabilities to identify implicated species/variants with a PCR-sequencing approach. This will allow for precise case identification with clear differentiation from PKDL and optimal treatment and control strategies can be implemented.

Note: Supplemental files appear at www.ajtmh.org.