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STUDIES
Year : 1993  |  Volume : 59  |  Issue : 4  |  Page : 172-175

Post kala-azar dermal leishmaniasisa clinico-pathologic study




Correspondence Address:
S M Sinha


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  Abstract 

Post kala-azar dermal leishmaniasis (PKDL), a rare cutaneous lesion is now occurring with increasing frequency in endemic zones in India. Analysis of 20 cases of PKDL revealed previous history of kala-azar in all cases. Types of skin lesions were : hypopigmented macular (75%), erythematous macular (15%) and nodular (10%). Lesions were present mostly in face (64%). Amastigotes of L. donovani were present in 60% of dermal scraping smears and 50% cases on histopathologic examination. Histopathologically 80% showed non-specific mononuclear infiltration, including all the hypopigmented lesions. Amastigotes were detected in 37.5% of these cases. Non-specific compact granuloma was observed in 20% cases including 2 cases each of erythematous and nodular types. Parasites were detected in all these cases.


Keywords: Post kala-azar dermal leishmaniasis, Leishmania donovani, cutaneous leishmaniasis


How to cite this article:
Sinha S M, Gupta G, Ghosh R N, Ganguly U, Das A G. Post kala-azar dermal leishmaniasisa clinico-pathologic study. Indian J Dermatol Venereol Leprol 1993;59:172-5

How to cite this URL:
Sinha S M, Gupta G, Ghosh R N, Ganguly U, Das A G. Post kala-azar dermal leishmaniasisa clinico-pathologic study. Indian J Dermatol Venereol Leprol [serial online] 1993 [cited 2020 May 27];59:172-5. Available from: http://www.ijdvl.com/text.asp?1993/59/4/172/3922



  Introduction Top


Post kala-azar dermal leishmaniasis (PKDL) is a rare non-ulcerative cutaneous lesion occurring in kala-azar patients after 1 to 5 years of apparent recovery in a small number of patients, where the visceral infection disappears but the skin infection persists. Nowadays such lesions are being observed with increasing frequency in our country. It is particularly prevalent in the endemic zones of kala-azar in India, chiefly in Bihar and West Bengal. The clinical manifestations as well as the pathologic features are widely variable. The clinicopathological study of 20 such cases is reported here.


  Materials and Methods Top


Twenty patients presenting with skin lesions resembling PKDL during a period of five years (April 1987 - March 1992) have been included in this study. Detailed

clinical history, past history of kala-azar infection and treatment thereupon were recorded. The clinical examination of the local lesion was done. The haemoglobin estimation and aldehyde test were performed. Bone marrow examination by sternal puncture was made in 10 cases. Skin smear examination by dermal scraping for Leishmania donovani (LD bodies) and biopsy examination of the skin lesions was performed in all the cases.

All the patients were treated with Inj. sodium stibogluconate 5 ml intramuscularly daily for 2 weeks, repeated twice more in the same dose at a gap of 2 weeks each time.


  Results Top


The observations of clinical findings have been depicted in [Table - 1]. Fifteen patients (75%) had hypopigmented macular lesion and in all these cases lesion in the face was present. More than one lesion were present in 5 cases. Erythematous lesion was observed in 3 cases (15%) and the remaining two cases had papulonodular type of skin lesion [Figure - 1]. The investigational findings have been shown in [Table - 2]. LD bodies could be demonstrated in 12 cases (60%) of dermal scraping smear [Figure - 2]. Eight of these were from hypopigmented macular lesion and 4 were from the nodular and erythematous lesions.

Histopathologically 16 cases (80%) had non-specific mononuclear infiltrate in upper dermis and 4 cases (20%) showed compact granuloma. Out of the 16 cases with non-specific mononuclear infiltrates 15 belonged to the hypopigmented macular lesions. Out of the 3 cases of erythematous macular type, 1 showed non-specific mononuclear infiltrate and 2 showed compact granuloma. Both the cases of nodular lesions showed compact granuloma. LD bodies could be demonstrated in biopsy of 10 cases (50%) which included 4 cases of compact granuloma comprising 2 cases each of erythematous and nodular lesions, and 6 cases with non-specific mononuclear infiltrate belonging to hypopigmented macular type [Figure - 3] [Table - 3].

With a single course of treatment the lesions healed completely in 15 cases (75%). In 4 cases (20%) a second course was required for healing. The remaining case, needed two more courses for resolution of lesions. No toxic effect with the treatment developed in any patient.


  Comments Top


Clinicopathological study of PKDL cases showed a positive past history of kala-azar in all cases with inadequate treatment during initial illness. All the patients were young with a marked male preponderance. Such observations are well documented in literature and females are probably protected by the female sex hormones.[2],[4] Our study commensurates well with reported observations of hypopigmented type of lesion and face being the commonest type and site of lesion. [4],[5],[6] Anaemia and hepatosplenomegaly were constant features, which were probably due to the patients suffering from systemic kala-azar in recent past. Although there are reports of 100% positive demonstration of LD bodies in dermal smears, [6] we could demonstrate them in 60% cases only. The histopathologic features are usually a non­specific granulomatous lesion and LD bodies are demonstrated in a few of them. [4],[7],[8],[9] We have also observed non­ specific mononuclear infiltrate in 80% cases and compact granuloma in the rest. The parasite was demonstrated in 50% of tissue sections . However the parasites were scanty. In 6 cases no parasites could be demonstrated either in dermal smear or tissue section. In these cases the diagnosis was confirmed as the lesions healed completely with specific treatment of sodium stibogluconate. Treatment with sodium stibogluconate has shown excellent result. Majority (75%) were cured with a single course, the remaining the additional courses. No toxic effect was observed with the drug.

We may thus conclude that although the clinical features of PKDL are more or less characteristic, the pathologic features are not always confirmatory as it is often not possible to demonstrate the parasite in local lesions. In such cases one has to depend on the clinical features and response to treatment.

 
  References Top

1.Chatterjee: Dermal leishmanoid. In: Parasitology. 12th edn. Calcutta: Chatterjee Medical Publishers, 1980; 64-5.  Back to cited text no. 1    
2.Saran R, Sharma MC, San AB. Quantitative grading of Leishmania donovani amastigotes related to age of kala-azar patients. J Commun Dis 1989; 21 : 262-4.  Back to cited text no. 2    
3.Sharma MC, Gupta AK, Saran A, et al. The effect of age and sex on incidence of kala­azar. J Common Dis 1990; 22 : 277-8.  Back to cited text no. 3    
4.Rai RN, Kumar M, Srivastava A, et al. Clinico-epidemiological profile pf post kala­azar dermal leishmaniashis in Varanasi. J Commun Dis 1989; 21 : 214-7.  Back to cited text no. 4  [PUBMED]  
5.Majumdar TD. Post kala-azar dermal leishmaniasis. Derm Int 1967; 6 : 174.  Back to cited text no. 5  [PUBMED]  
6.Thakur CP, Kumar K. Efficacy of prolonged treatment with stibogluconate in post kala­azar dermal leishmaniasis. Ind J Med Res 1990; 91 : 144-8.  Back to cited text no. 6  [PUBMED]  
7.Girgla HS, Marden RA, Singh GM, et al. Post kala-azar dermal leishmaniasis. Br J Dermatol 1977; 97 : 307-11.  Back to cited text no. 7    
8.Gupta PC, Bhattacharjoe B. Histopathology of post kala-azar dermal leishmaniasis. J Trop Med Hyg 1953; 56 : 110-7.  Back to cited text no. 8    
9.Yesudian P, Thambiah AS. Amphotericin B­therapy in dermal leishmanoid. Arch Dermatol 1974; 109 : 720-2.  Back to cited text no. 9  [PUBMED]  


    Figures

[Figure - 1], [Figure - 2], [Figure - 3]

    Tables

[Table - 1], [Table - 2], [Table - 3]



 

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