Dermatology Online Journal

Clinico-epidemiologic study of cutaneous leishmaniasis in Diyarbakir Turkey
S Aytekin¹, M Ertem², O Yağdıran¹, N Aytekin³
Dermatology Online Journal 12 (3): 14

Departments of Dermatology¹, Public Health², Medical School of Dicle University, and Diyarbakır State Hospital³ Diyarbakir, TURKEY. saytekin@dicle.edu.tr

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Abstract

Cutaneous leishmaniasis (CL) is a zoonotic disease, endemic and notifiable in southeastern Turkey. We investigated clinical features, individual characteristics, and environmental factors of affected patients, and identified additional patients with CL in Diyarbakir. In 2002 we studied the epidemiology of CL in Dedeköy and Durabeyli towns in Diyarbakir Province. We evaluated patients with any skin lesions. A questionnaire including demographic details was completed by each patient. Clinical details of lesions and other dermatological findings were recorded. We walked around the town and surveyed it for environmental factors. CL was diagnosed in 78 individuals aged 1-85 years (mean age of 20). Although all age groups were affected, the majority of patients were under age 20. The lesions ranged from approximately 0.5 to 20 cm. They were located on the face (46.7 %), upper extremity (23.2 %), lower extremity (5.1 %), and other sites. Different types of lesions were observed such as nodule with crust, nodule with osseous crust, violaceous infiltrative plaque with vegetative nodule, erysipelas-like plaque verrucous annular plaque, and eczema-like plaques. The incidence of CL is increasing in Dicle and Durabeyli towns and the clinical appearance may vary greatly.

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Introduction

Cutaneous leishmaniasis (CL) is a notifiable zoonotic disease and endemic in the southeastern Turkey. Diyarbakir province is the southern province of Turkey with a population of approximately one million people. It is located near the shores of the Tigris River and on a high basalt plateau at an elevation of 650 meters above sea level. In the 1950s, CL was endemic in the southeastern region of Turkey in such areas as Diyarbakir, Sanliurfa, and Adana, and was characterized by anthroponotic epidemics [1]. The incidence of CL decreased after the elimination of sand fly vectors with DDT, which had been used against mosquitoes in the eradication of malaria; however, by 2000, its incidence increased in the province of Diyarbakir. In our department the patients with CL numbered 0-7 in preceding years, but reached 20 in the first half of 2002. Almost all of the patients were from Dicle and Durabeyli towns of Diyarbakir and have populations of approximately 4000. We investigated the patients' clinical and lesional characteristics and the local environmental features. We also sought to identify other patients with CL.

Patients and methods

Figure 1	Figure 2

We visited the affected towns in June 2002, observing persons who had skin lesions. The majority of young people were working in the fields, and were unavailable for observation. Patients with CL were diagnosed clinically or by the demonstration of the parasite in a Giemsa-stained smear taken from a lesion. A questionnaire was administered to each patient, including all demographic details such as name, sex, residence, occupation, family history, and house features. Clinical details such as date of disease onset, presumed place of infection, body site, number of lesions, and other dermatological findings were recorded. The presence of other diseases and use of drugs related to CL were noted. We examined for the presence of BCG scars. We walked around the towns and recorded environmental factors.

Results

CL was diagnosed in 78 individuals ranging in age from 1 to 85 years (mean age 20.5 years). The majority of patients (66.7 %) were less than 20 years of age, with the highest percentage (37.2 %) in the 0-9 year age group. The patients reported the duration of the lesions to be 1-36 months. A positive family history was reported in 63.3 percent of cases.

Both sexes appear to be equally involved. Uncovered parts of the body, the face and limbs, are mostly involved. Lesions are located on the face only (46.7 %), upper extremity (23.2 %), lower extremity (5.1 %), face and upper extremity (20.5 %), face and lower extremity (1.3 %) and face and upper and lower extremity (2.6 %). Mucosal lesions were seen on the mucocutaneous borders of the eyelids, lips, and nostrils in 3 (3.8 %) patients. Leishmania tropica was identified by Giemsa-stained smear which was taken from lesions in 25.6 percent of patients.

The number of lesions per patient ranged from 1 to 9. A single lesion was found in 47.4 percent of the patients, 2-4 lesions in 47 percent, and 5 or more lesions in 5.1 percent of the patients. The patients with 5 or more lesions had some other underlying disease or reason for immunosuppression. For instance, one had lymphoma, one had tumor, one had scrofuloderma, and one was pregnant. The lesions varied from a few mm to 20 cm in diameter.

Different types of lesions were observed, such as nodules with or without crust, nodules with osseous crust, violaceous infiltrative plaque with vegetative nodule, erysipelas like plaques (Fig. 1), verrucous annular plaques (Fig. 2), and impetiginous or eczema-like lesions. There were BCG scars in 37.2 percent of patients.

Dedeköy and Durabeyli towns are close to the river dam. There were buildings with two floors, the first floor was stall and second floor was used as a residential flat. The stall was dark and damp. Its walls were made from hallow stones. There was brush and a dunghill near the houses. The toilets were outdoors and uncovered. The questionnaire results indicated that there were rodents near the houses and people were sleeping on the roofs of the house at night on hot summer days.

Discussion

The cutaneous leishmaniases are endemic in 82 countries of the World, and the World Health Organization estimates an incidence of 12 million cases amongst 350 million at risk, and an annual incidence of 600,000 cases. The leishmaniases are present in all the countries around the Mediterranean [2, 3, 4].

In the 1950s, CL was endemic in the southeast region of Turkey and was characterized by anthroponotic epidemics [1, 5]. Although the disease seemed to have been under control since 1981, its incidence increased in the city of Sanliurfa and an epidemic of 1741 cases occurred in 1983 [1, 6]. Gurel and collages reported that epidemiologic and clinical features of 2120 cases with CL in 1997-2000 [7]. Cutaneous leishmaniasis cases have been reported in different cities in Turkey such as Sanliurfa, Adana, Hatay, Antalya, Kayseri, Icel, Kahramanmaras, and Nigde [5, 6, 7, 8, 9, 10, 11]. The majority of the cases in Turkey have been reported in Sanliurfa [5, 6, 11]. A treatment center was established in Sanliurfa by the Ministry of Health, in which the diagnosis, treatment and follow-up of CL are provided free for patients. Therefore CL diagnosis and recording system in Sanliurfa is highly reliable. Diyarbakir and adjacent Sanliurfa and have similar geographic and climatic features. The climate is subtropical, hot, and dry in summers and cool and moist in winter. There was no special center for CL in Diyarbakir. Although there were many patients with CL in the rural area of Diyarbakir, few patients with common and destructive lesions were admitted to the hospitals.

In our study, we identified 78 patients with CL in these towns. Although all age groups are affected, the majority of patients were under age 20 years. This could be due to the fact that older people may be more resistant to the bites of sand flies than younger children, and the young have more outdoor activities and are more exposed to the bites of sand flies. Furthermore most of the older people could have been infected during their early childhood in the high-prevalence years.

There were multiple lesions in five patents. Three of these patients had lymphoma, brain tumor, or scrofuloderma, and another patient was pregnant. Dissemination in cutaneous leishmaniasis may be the result of lack of cell-mediated immunity to leishmanial antigen, thus resulting in uncontrolled growth of the parasite [12]. Many clinical presentations are reported, such as nodular, hyperkeratotic, eczematoid, sporotrichoid, zosteriform, warty, impetiginized, erysipeloid, and lupoid forms [8, 10, 13]. Different types of lesions, including nodular, erysipelas like, eczematoid, warty, hyperkeratotic, and impetiginous were also observed in our study. Atypical and treatment-resistant eruptions, especially involving the uncovered part of the body, should be evaluated for CL in endemic areas.

The southeastern Anatolia Irrigation Project or GAP (its Turkish acronym) is one of the largest projects ever undertaken in Turkey. This water resources development program includes the construction of 22 dams and 19 hydroelectric plants on the Euphrates and Tigris rivers in southeastern Turkey [14]. Many environmental changes occurred from this project; because of this the activities of the sand flies and other vector insects increased. These factors are blamed for worsening the progress against leishmaniasis and the resulting explosion in its incidence.

The vector of CL in the Diyarbakir province has not been reported. Currently, a total of 18 species of sand fly have been reported in Turkey, including the subgenera Adlerius, Larroussius, Paraphlebotomus and Phlebotomus. Populations of Phlebotomus papatasi, P. sergenti, and P. perfiliewi have increased in Sanl urfa, which is the center of the GAP project [5, 6, 11, 14, 15, 16]. The epidemiology of the CL is strongly correlated with the ecology, temporal and geographical distribution of the vector, and the reservoir. The activities of the sand fly are strongly correlated with the level of rainfall and temperature. The presence of infected rodents in the area, extensive land reclamation, and irrigation practices that might have caused unnatural moist soil, lead to an increase in the density of sand fly populations.

Cutaneous leishmaniasis eventually heals. The rate of spontaneous healing depends on several factors, including parasite load and virulence, host immune response, location of the lesion, and the presence or absence of secondary bacterial infection. Host immune response can be increased with Calmette-Guerin (BCG) vaccination. BCG, a non-specific immunostimulant, significantly reduced CL severity in mice in an experimental study [17]. A treatment of secondary bacterial infection is essential for healing. Immunocompromised patients should be treated immediately. The goal of therapy must be to have a cosmetically acceptable scar or to have no scar.

Our results show that CL is an important health problem in the rural area of Diyarbakir. The incidence of CL is increasing in Dicle and Durabeyli. It is believed that the hot climate, river dam, old buildings, poor hygiene, and relaxation in insecticide spraying campaigns for malaria control are the main factors responsible for recent outbreaks. Preventive methods and urgent precautions should be undertaken. The physical conditions of the houses and buildings should be upgraded. Persons who live in an endemic area should be trained about CL, sand fly life cycles, and preventive measures. In addition, the possible benefit of BCG vaccination should be considered.

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