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

Abstract

BackgroundThe South-East Asia Region Kala-azar Elimination Programme (KAEP) is expected to enter the consolidation phase in 2017, which focuses on case detection, vector control, and identifying potential sources of infection. Post-kala-azar dermal leishmaniasis (PKDL) is thought to play a role in the recurrence of visceral leishmaniasis (VL)/kala-azar outbreaks, and control of PKDL is among the priorities of the KAEP.Methodology and principal findingWe reviewed the literature with regard to PKDL in Asia and interpreted the findings in relation to current intervention methods in the KAEP in order to make recommendations. There is a considerable knowledge gap regarding the pathophysiology of VL and PKDL, especially the underlying immune responses. Risk factors (of which previous VL treatments may be most important) are poorly understood and need to be better defined. The role of PKDL patients in transmission is largely unknown, and there is insufficient information about the importance of duration, distribution and severity of the rash, time of onset, and self-healing. Current intervention methods focus on active case detection and treatment of all PKDL cases with miltefosine while there is increasing drug resistance. The prevention of PKDL by improved VL treatment currently receives insufficient attention.Conclusion and significancePKDL is a heterogeneous and dynamic condition, and patients differ with regard to time of onset after VL, chronicity, and distribution and appearance of the rash, as well as immune responses (including tendency to self-heal), all of which may vary over time. It is essential to fully describe the pathophysiology in order to make informed decisions on the most cost-effective approach. Emphasis should be on early detection of those who contribute to transmission and those who are in need of treatment, for whom short-course, effective, and safe drug regimens should be available. The prevention of PKDL should be emphasised by innovative and improved treatment for VL, which may include immunomodulation.

Vigilância da leishmaniose cutânea em amostras clínicas: distribuição da Leishmania guyanensis no estado do Amapá, 2018*

“…1 L. naiffi infection in humans is limited to the states of Amazonas, Acre, Pará, Rondônia and Mato Grosso, 16 with no complications having been reported until our study revealed the first case of CL caused by L. naiffi in Amapá. L. infantum is phylogenetically close to Leishmania donovani, the agent that causes VL and post-kala-azar dermal leishmaniasis in the Old World (Europe); 17 occurrence of cutaneous lesions caused by L. infantum in immunocompetent individuals is uncommon in the Americas, especially in Brazil. 14,18 L. infantum has been isolated in the skin of Africans with CL, producing a lesion histologically distinct from that caused by L. major.…”

Male predominance in reported Visceral Leishmaniasis cases: Nature or nurture? A comparison of population-based with health facility-reported data

“…One recurrent observation is that patients treated for VL in health services are predominantly male [2,3]. This is not limited to the Indian subcontinent but was observed across different geographical locations, over different leishmanial species and disease spectra, including cutaneous forms of leishmaniasis [2,[4][5][6]. Two hypotheses have been formulated to explain this difference between both sexes, stressing either social differences between men and women (i.e., gender differences, relating to the specific behavior, activities, and roles of men and women in society) or biological differences (i.e., sex differences) [7].…”

Advanced case of PKDL due to delayed treatment: A rare case report

“…Miltefosine is currently being used as anti-parasitic oral drug for treating PKDL which can easily accessible and safe to use [11,12]. Previous study also demonstrated the treatment with miltefosine for 12 weeks (50 mg twice per day) has a cure rate of 93% (per protocol [PP] analysis) [13]. In Indian subcontinent, PKDL cases are treated according to national guidelines with miltefosine for 12 weeks with miltefosine.…”