Childhood cutaneous leishmaniasis: Experience of a Moroccan unit of dermatology
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https://doi.org/10.5070/D39v21h3k8Main Content
Childhood cutaneous leishmaniasis: Experience of a Moroccan unit of dermatology
S Qasmi, N Elguelbazouri, FZ Belgnaoui, T Marcil, J Bouhllab, K Senouci, M Aitourhoui, B Hassam
Dermatology Online Journal 14 (12): 18
Dermatology Unit, Ibn Sina University Hospital, Rabat, Morocco. safaeqasmi@yahoo.frAbstract
OBJECTIVE: We undertook a monocentric retrospective analysis of childhood leishmaniasis in order to describe the epidemio-clinical profile, therapeutic characteristics and clinical outcomes of affected patients. PATIENTS AND METHODS: The files of all children treated for cutaneous leishmaniasis (CL) in the Dermatology Department of Ibn Sina University Hospital over an 11-year period were reviewed. RESULTS: A total of thirteen children were included. The mean age was 10.2 years and the sex ratio (F/M) was 5.5. All patients lived or had stayed in an endemic area. The average delay of diagnosis was 11.8 months. The most frequent clinical finding consisted of ulcers (61.5%), usually located on the face (69.2%). The clinical diagnosis was confirmed by parasitologic smear in 76.9 percent of cases. The treatment used was intralesional meglumine antimoniate in twelve cases. The outcome was favorable in all cases. CONCLUSION: Our series is characterized by a female predominance and the patients presented with a single lesion. The lesions were frequently located on the face and a favorable outcome was obtained after treatment with intralesional meglumine antimoniate.
Introduction
Leishmaniasis is an anthropozoonosis due to a protozoan that is transmitted by the sandfly. Cutaneous infection can arise at any age and often causes cosmetic disfiguration [1, 2]. There are few series concerning childhood cutaneous leishmaniasis (CL) in the literature. The aim of this work was to study the epidemio-clinical profile, the therapeutic characteristics, and the evolution of this infection in Moroccan children.
Material and methods
Our study is a monocentric restrospective study of patients followed-up for CL in the dermatology unit in Ibn Sina University Hospital of Rabat between January 1995 and December 2005. This study included only patients less than 16. The clinical diagnosis was confirmed by parasitologic smear and sometimes histological examination. Parasitologic smear was prepared after a skin scraping. The resulting tissue was smeared on a slide and allowed to air dry. A rapid Giemsa stain was performed. The parasitologic smear was considered positive when it showed leishmanial parasites as amastigotes, generally intracellular inside monocytes.
For every patient, the following parameters were recorded: the age, the sex, the exact geographic origin, history of travel to an endemic area, a family history of leishmaniasis, the average delay of diagnosis (time between the appearance of the symptoms and the consultation in our unit), the type of lesions, the number and the site of the lesions, the results of the parasitologic smear, the results of histopathologic study, the administered treatment, and the results of treatment.
Results
Our study concerned thirteen cases of CL. The childhood cases represented 46.4 percent of all the cases of CL followed up in our unit during the same period. The average age of the patients was 10.2 years ± 5.4 (range: 2-16 years). The sex ratio (F/M) was 5.5. Seven patients (53.8%) live in an endemic area (notably Ouarzazate and Zagoura, in the South of Morocco and Taza, in the east of the country). Six children (46.1%) had traveled to an endemic area. There was a family history of CL in two cases (15.3%). The average delay of diagnosis was 11.8 months (range: five months to two years). All the patients presented a single lesion. These lesions were localized on the face in nine cases (69.2%), onI the cheeks. Lesions affected the neck in three cases (23%) and the forearm in one case (7.69%). We encountered three clinical forms of CL: the ulcer form in eight cases (61.5%), the nodular form in four cases (30.7%), and the furunculoid type in one case (7.69%). Parasitologic examination was positive in ten cases (76.9%). Histopathological study confirmed the diagnosis in three cases (23%) in whom the parasitologic smear was negative. These showed a granulomatous dermal infiltrate with the presence of plasmocytes and epithelioid cells. There were microfocuses of fibrinoid necrosis in two cases. Giemsa stain revealed amastigotes, which appear pale blue.
Twelve patients were treated with intralesionnal meglumine antimoniate (ampules of 5 ml containing 1.5 g of meglumine antimoniate). It was given as one intradermal injection (2-5 ml per injection) per week, in the four cardinal points of the lesions, over 3-5 weeks. Each injection contained 1 ml of xylocaine, 1 percent, to reduce the pain related to the injection.
No patient was treated with systemic meglumine antimoniate. The intralesional meglumine antimoniate was well tolerated in all patients. The pain related to the injections was small. This treatment was effective in all cases and a complete clinical clearance was obtained within an average period of six weeks. The average follow-up was 3 months. Complete healing without scars was observed in eight patients (61.5%). Hyperpigmented or hypopigmented scars were seen in two cases (15.3%) and an atrophic scar in two cases (15.3%). One child was lost to follow up before receiving any treatment.
Discussion
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Our series is characterized by a female preponderance and a majority of the cutaneous lesions were ulcers. The average delay to consultation, relatively long in our series, could be explained essentially by the painless character of the lesions. In our knowledge, there are only few published series in the literature concerning childhood cutaneous leishmaniasis. The average age of our patients was lower than that of the patients of an Algerian series and higher than that of the patients of a Tunisian series [2, 3]. Female preponderance was noted in our series and the most common lesion type was an ulcer similar to the Tunisian report [3]. Numerous clinical presentations are possible: papulo-nodular, lupoid, sporotrichoid, impetiginous, and erysipeloid [2, 4]. The lesions are often single and localized very frequently in the face; this site is easily accessible to the sandfly [2, 3, 5]. Our series is characterized by a frequent involvement of cheeks (Fig. 1), whereas in a Tunisian series, the lesions were also localized to the lips, the forehead and the nose [2].
To confirm the diagnosis, it is necessary to prepare a parasitologic examination [6, 7].The history can reveal a family history of cutaneous leishmaniasis in 5 percent of the cases [2]. In our series 15.3 percent of the patients reported the existence of similar cases in the family. A long delay to diagnosis, noted in our series, was also found in other reports [2, 3]. The treatment of cutaneous leishmanisis has changed little for several years. Intralesional meglumine antimoniate is the treatment of choice for this type of localized disease. This treatment was effective and well tolerated in our patients. Intramuscular injections of meglumine antimoniate can be used in case of periorificial involvement (eyelids), multiple lesions (>5), poor response to local treatment, satellite lesions testifying cutaneous or lymphatic dissemination, and in the case of regional lymphadenopathy [8]. Other treatments suggested in the literature include amphotericin B, ketoconazole, fluconazole, dapsone, azithromycin, and rifampin. In addition surgery, cryotherapy, laser, and intralesional bleomycin have been successfully used. Other medications, such as allopurinol, atovaquone, or interferon alfa have been used in the treatment of the LC. These treatments have a very limited use because they have not been subjected to randomized evaluations [6, 9, 10, 11, 12].
Conclusion
Through this series of children with cutaneous leishmaniasis, we observed a high frequency of the ulcerated form of CL, localized to the face. A good response to treatment with intralesional meglumine antimoniate was obtained in each case. We emphasize the necessity to adopt measures of prevention in the endemic areas to reduce the incidence of this infection that can cause facial disfigurement.
References
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