Clinicopathological and Immunological Changes in Indian Post Kala-Azar Dermal Leishmaniasis (PKDL) Cases in relation to Treatment: A Retrospective Study

Abstract

Post-kala-azar dermal leishmaniasis (PKDL) is an important factor in kala-azar transmission; hence its early detection and assessment of effective treatment is very important for disease control. In present study on 60 PKDL cases presented with macular, mixed papulonodular, or erythematous lesions, Leishmania parasites were demonstrated microscopically in 91% of papulonodular and 40% of macular lesions. Cellular infiltrates in skin biopsy imprint smears from lesions were mononuclear cells, 25–300/OIF (oil immersion field), predominantly histiocytes with vacuolation, many lymphocytes, some plasma cells, and Leishmania amastigotes 0–20/OIF. Cases with no demonstrable parasites were diagnosed on the basis of past history of VL, lesion's distribution, cytopathological changes, and positive DAT (86.83%). Following antileishmanial treatment with SAG, papulonodular forms of PKDL lesions disappeared clinically but microscopically the mononuclear cells (20–200/OIF) persisted in the dermal lesions. Response observed in macular PKDL lesions was poor which persisted both clinically and cytopathologically. Follow-up of PKDL will assess the effectivity of treatment as either disappearance of lesions or any relapse. Studies on involvement of immunological factors, that is, certain cytokines (IL-10, TGF-β, etc.) and chemokines (macrophage inflammatory protein, MIP 1-α, etc.) in PKDL, may provide insight for any role in the treatment response.

Post-kala-azar dermal leishmaniasis in the Indian subcontinent: A threat to the South-East Asia Region Kala-azar Elimination Programme.

“…While in hospital-based studies in nonendemic areas a male preponderance (80%) is reported among PKDL patients with a male-to-female ratio of 3–4:1, in endemic areas, the ratio seems much more balanced (ratio 1.2–1.9) and not different from that found in VL [ 10 – 12 , 14 , 27 – 29 ].…”

“…In slit-skin smears, macular lesions will often fail to show parasites, while PN lesions will be positive in 20%–40% [ 13 , 50 ]. The yield is higher in a biopsy (imprint smears): 91% of PN lesions and 40% of macular lesions will show parasites [ 12 ]. Culture and immunohistochemical (IHC) staining improve routine haematoxylin–eosin staining [ 27 ].…”

“…While the parasite load in PKDL is lower than in VL, a long duration of antileishmanial therapy is often given because there is no conclusive laboratory or clinical marker other than the disappearance of the lesions. In the case of macular lesions, this may take 12–18 months [ 10 , 12 ]. While in histological specimens after 3 months of treatment (SSG 10 mg/kg/day for 90 days) parasites can no longer be detected by microscopy, the mononuclear cell infiltrate still persists [ 12 ].…”

“…In the case of macular lesions, this may take 12–18 months [ 10 , 12 ]. While in histological specimens after 3 months of treatment (SSG 10 mg/kg/day for 90 days) parasites can no longer be detected by microscopy, the mononuclear cell infiltrate still persists [ 12 ]. Both LAMP and qPCR could be useful, and the latter allows the comparison of the parasite (load) before and after treatment [ 52 ].…”

Predicting death from kala-azar: construction, development, and validation of a score set and accompanying software

“…Both are important opportunistic infections among patients with acquired immunodefi ciency syndrome (AIDS) (14) (15) (16) and have similar clinical presentations, but L. donovani may lead to post-kala-azar dermal leishmaniasis, or infectious skin lesions (17) (18) .…”