Clinical manifestations and distribution of cutaneous leishmaniasis in pakistan.

Hindawi Publishing Corporation
Journal of Tropical Medicine
Volume 2011, Article ID 359145, 8 pages
doi:10.1155/2011/359145
Review Article
Clinical Manifestations and Distribution of Cutaneous
Leishmaniasis in Pakistan
Abaseen Khan Afghan, Masoom Kassi, Pashtoon Murtaza Kasi, Adil Ayub,
Niamatullah Kakar, and Shah Muhammad Marri
Department of Pathology, Bolan Medical College, 8-13/36 Kasi Road, Balochistan, Quetta 87300, Pakistan
Correspondence should be addressed to Pashtoon Murtaza Kasi, pashtoon.kasi@gmail.com
Received 30 June 2011; Accepted 6 September 2011
Academic Editor: Cristina Riera
Copyright © 2011 Abaseen Khan Afghan et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Cutaneous leishmaniasis (CL) is a rising epidemic in Pakistan. It is a major public health problem in the country especially
alongside regions bordering the neighboring Afghanistan and cities that have had the maximum influx of refugees. The purpose
of our paper is to highlight the diverse clinical manifestations of the disease seen along with the geographic areas affected, where
the hosts are particularly susceptible. This would also be helpful in presenting the broad spectrum of the disease for training of
health care workers and help in surveillance of CL in the region. The increased clinical diversity and the spectrum of phenotypic
manifestations noted underscore the fact that the diagnosis of CL should be not only considered when dealing with common
skin lesions, but also highly suspected by dermatologists and even primary care physicians even when encountering uncommon
pathologies. Hence, we would strongly advocate that since most of these patients present to local health care centers and hospitals,
primary care practitioners and even lady health workers (LHWs) should be trained in identification of at least the common
presentations of CL.
1. Background
Cutaneous leishmaniasis (CL) is a rising epidemic in Pakistan
[1]. It is a major public health problem in the country es-
pecially alongside regions bordering the neighboring Af-
ghanistan and cities that have had the maximum influx of
refugees [2]. Pakistan in particular, as highlighted by Postigo,
has been a focus of both anthroponotic cutaneous leishma-
niasis caused by Leishmania tropica (L. tropica) and zoonotic
CL caused by Leishmania major (L. major) with epidemics
occurring in various parts of the country [3]. L. tropica is
mostly seen in urban areas whereas L. major is more common
in rural areas of the country [4].
The purpose of our paper is to highlight the diverse
clinical manifestations of the disease seen along with the
geographic areas affected where the hosts are particularly
susceptible. This would also be helpful in presenting the
broad spectrum of the disease for training of health care
workers and help in surveillance of CL in the region [3].
2. Methodology for Our Review
We searched the terms “cutaneous”, “leishmaniasis,” and
“Pakistan,” in Pubmed which retrieved a total of 67 articles.
These articles were then systematically reviewed with focus
on the number of people affected in different areas of the
country and the clinical manifestations of the disease doc-
umented by the authors. A summary of the studies selected
is outlined in Table 1. References citing other studies done
in the region were then also studied for the aforementioned
objectives.
3. Clinical Manifestations of
Cutaneous Leishmaniasis
CL is usually noted on exposed parts of the body, mainly
arms, face, and legs. The clinical manifestations are extremely
diverse including unusual sites and atypical morphologies.
Typically, the natural course of the lesions seen in CL is

2 Journal of Tropical Medicine
outlined by Figure 1. The lesions typically are not painful,
but are associated with significant stigma associated with
the disease (Figure 2). Women and children are particularly
affected. As noted, however, it is increasingly seen in var-
ious unusual forms, for example, as fissures on lips, with
lupoid features on face and/or psoriasiform plaques on nose
[5, 6]. The myriad of manifestations seen is an outcome
of the interplay between the parasite infection and host’s
immune responses [4]. “On one end of the spectrum of
CL is the classical oriental sore in which spontaneous cure
and immunity to reinfection is the result of an effective
parasiticidal mechanism. On the other end of the spec-
trum is diffuse cutaneous leishmaniasis in which metastatic
cutaneous lesions develop and the patient rarely, if at all,
spontaneously develops immunity to the parasite” [7].
4. Causative Agent in Pakistan
The main causative agent noted in our review of the studies
was L. major followed by L. tropica. This was also highlighted
in a review on molecular epidemiology of leishmaniasis in
Asia, where in southern dry areas of the country, L. major was
seen more often [28]. However, as noted by Katakura as well
as Marco et al., there was no clear association between the
skin lesions and the type of leishmaniasis, probably referring
to host factors and immunoinflammatory responses being
more important in determining the type and severity of
lesions noted [28–31]. Likewise, no correlation between
the type of CL lesions and the causal leishmania parasites
was noted in a gene sequencing study on samples from
both provinces of Sindh and Balochistan [14]. However, as
outlined in Table 1, in the same study, there was indeed
an association between the type of leishmania parasite and
the altitude of the region, with L. major (97.9%) being the
predominant type of parasite in lowland areas, while L.
tropica (76.2%) was more common in highland areas [14]. L.
tropica was also the strain most commonly found in a study
from Multan and another study with a small sample size from
various parts of the country [32, 33]. Clinical presentations
appear to vary by endemic regions [31].
5. Distribution of Cutaneous Leishmaniasis
in Pakistan
The country Pakistan is divided into 4 provinces: Punjab,
Sindh, Khyber Pakhtunkhwa, and Balochistan along with
Azad Jammu Kashmir (AJK). As noted from the research
studies cited in Table 1, some parts of the country are more
affected than others (Figure 3).
Balochistan, the largest province by area located in the
southwest of Pakistan, appears to have taken a significant
toll followed by Khyber Pakhtunkhwa [9]. The geographic
distribution, as noted by Firdous et al., is a function of
the sandfly vector compounded with activities disturbing
their habitat including wars as well as deforestation and
agricultural activities [4, 34]. Breeding of animals is also
thought to play a contributory role, along with “dark niches
and cracks in the ground providing suitable habitat for the
sandflies” [24, 28]. Within Balochistan, areas where most
Red papular lesion
a period of several weeks
and ulcer formation
Healing: atrophy
leading to scar
formation
Incubation period (<2 months for
L. tropica and >2 months for L. major)
The papule enlargement then occurs over
Crusting, induration,
Healing: 2–6 months for L. major;
8–12 months for L. tropica infection
Figure 1: Typical sequence of events leading to the formation of
the typical oriental or “yearly sore” called “kal dana.” Description
adopted from excellent review by Arfan u Bari et al., 2009. Picture of
Sandflies obtain through the courtesy of Bruce Alexander, Research
Fellow in Molecular and Biochemical Parasitology Group, Liverpool
School of Tropical Medicine.
patients have been reported from are Quetta, Ormara, and
Uthal [35]. Quetta is a metropolitan city and the capital of
the province. Reasons for more cases of CL being reported
from the capital of the province are that people belonging
to different castes live there along with many refugees who
were from the adjacent war-torn country of Afghanistan and
migrated during the early 1980s and 1990s [1]. The hospitals
and clinics serve as major teaching/tertiary care centers
not only for the entire province but also for neighboring
adjoining areas of Afghanistan.
The increased incidence noted in some parts of the
country where major teaching hospitals and where most of
the research studies are conducted may be a function of
better awareness and more testing of chronic skin lesions
for CL. Since a lot of these hospitals and research centers
cater and serve as major referral centers for entire provinces
in some cases, the true incidence especially in outskirts
and rural areas is currently not exactly known and may be
an underestimate [11]. For example, even in the survey-
based study of thousands of school children, predominant
population affected were male children; the severity and the
proportion of women affected may not be entirely known
given sociocultural factors [9].
6. The Road Ahead
The increased clinical diversity and the spectrum of phe-
notypic manifestations underscore not only fact that the

Journal of Tropical Medicine 3
Ta
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4 Journal of Tropical Medicine
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17
]
20
07
A
bb
ot
ta
ba
d,
K
hy
be
r
Pa
kh
tu
n
kh
w
a
1
H
is
to
pa
th
ol
og
y
Ty
pi
ca
lb
ut
te
rfl
y-
lik
e
ra
sh
se
en
in
SL
E
(1
5)
Sa
le
em
et
al
.[
18
]
20
04
–2
00
6
K
ar
ac
hi
,S
in
dh
10
0
C
lin
ic
al
an
d
hi
st
op
at
ho
lo
gi
ca
l
ex
am
in
at
io
n
N
od
ul
es
,p
la
qu
es
,u
lc
er
s,
cr
us
te
d
ul
ce
rs
,l
up
oi
d
le
si
on
s,
an
d
pl
aq
ue
s
w
it
h
sc
ar
ri
n
g
w
er
e
m
ai
n
ly
n
ot
ed
(1
6)
B
hu
tt
o
et
al
.[
19
]
20
09
La
rk
an
a,
Si
n
dh
10
8
Po
ly
m
er
as
e
ch
ai
n
re
ac
ti
on
(P
C
R
)
L.
M
aj
or
(1
05
)
L.
Tr
op
ic
a
(3
)

Journal of Tropical Medicine 5
Ta
bl
e
1:
C
on
ti
nu
ed
.
Pe
ri
od
C
it
y/
pr
ov
in
ce
N
um
be
r
of
ca
se
s
M
et
ho
d
of
di
ag
n
os
is
Sp
ec
ie
s
of
Le
is
hm
an
ia
Ty
pe
of
le
si
on
s
se
en
(1
7)
U
lB
ar
ia
n
d
B
er
R
ah
m
an
[2
0]
20
04
–2
00
6
Pu
n
ja
b
an
d
K
hy
be
r
Pa
kh
tu
n
kh
w
a
60
Sl
it
-s
ki
n
sm
ea
r
an
d
hi
st
op
at
ho
lo
gy
P
re
se
n
ta
ti
on
ei
th
er
(a
)
w
et
ty
pe
(e
ar
ly
ul
ce
ra
ti
ve
,r
ur
al
)
or
(b
)
dr
y
ty
pe
(l
at
e
ul
ce
ra
ti
ve
,u
rb
an
)
(1
8)
R
ow
la
n
d
et
al
.[
21
]
19
97
T
im
er
ga
ra
,D
ir
,K
hy
be
r
Pa
kh
tu
n
kh
w
a
92
00
in
ha
bi
ta
n
ts
C
lin
ic
al
di
ag
n
os
is
;
sa
m
pl
e
of
ca
se
s
co
n
fi
rm
ed
w
it
h
m
ic
ro
sc
op
y
an
d
P
C
R
Po
ss
ib
le
L.
tr
op
ic
a
ba
se
d
on
N
oy
es
et
al
.[
22
]
38
%
of
th
e
92
00
in
ha
bi
ta
n
ts
bo
re
ac
ti
ve
le
si
on
s,
an
d
a
fu
rt
he
r
13
%
ha
d
sc
ar
s
fr
om
ea
rl
ie
r
at
ta
ck
s
(1
9)
M
uj
ta
ba
an
d
K
ha
lid
[2
3]
19
95
–1
99
7
M
ul
ta
n
,P
un
ja
b
30
5
G
ie
m
sa
-s
ta
in
ed
sm
ea
r
fr
om
th
e
le
si
on
A
ll
th
e
le
si
on
s
w
er
e
of
th
e
dr
y
ty
pe
.M
os
to
ft
he
le
si
on
s
(9
7%
)
w
er
e
pr
es
en
to
n
ex
po
se
d
ar
ea
s
of
th
e
bo
dy
(2
0)
A
yu
b
et
al
.[
24
]
19
99
–2
00
0
M
ul
ta
n
,P
un
ja
b
17
3
Sm
ea
r
fo
r
LD
bo
di
es
C
lin
ic
al
ly
al
lt
he
le
si
on
s
w
er
e
of
dr
y
ty
pe
,w
it
h
67
%
pr
es
en
to
n
le
gs
(2
1)
A
nw
ar
et
al
.[
25
]
20
04
K
hu
sh
ab
di
st
ri
ct
,P
un
ja
b
10
5
FN
A
C
of
th
e
le
si
on
fo
r
fi
rs
t4
ca
se
s;
on
ly
hi
st
or
y
an
d
cl
in
ic
al
as
se
ss
m
en
tf
or
re
m
ai
n
in
g
D
is
se
m
in
at
ed
fo
rm
s
n
ot
ed
in
m
ul
ti
pl
e
ca
se
s;
w
it
h
1
pa
ti
en
t
w
it
h
m
or
e
th
an
50
le
si
on
s
(2
2)
B
ar
ia
n
d
R
ah
m
an
[2
6]
20
02
–2
00
6
R
aw
al
pi
n
di
,S
ar
go
dh
a,
an
d
M
uz
aff
ar
ab
ad
71
8
pa
ti
en
ts
w
it
h
C
L;
st
ud
y
w
as
on
41
pa
ti
en
ts
w
it
h
un
us
ua
l
pr
es
en
ta
ti
on
s
C
lin
ic
al
an
d
hi
st
op
at
ho
lo
gi
ca
l
ex
am
in
at
io
n
C
om
m
on
un
us
ua
lp
re
se
n
ta
ti
on
s
n
ot
ed
w
er
e
lu
po
id
le
is
hm
an
ia
si
s
in
14
(3
4.
1%
),
fo
llo
w
ed
by
sp
or
ot
ri
ch
oi
d
5
(1
2.
1%
),
pa
ro
ny
ch
ia
l3
(7
.3
%
),
lid
le
is
hm
an
ia
si
s
2
(4
.9
%
),
ps
or
ia
si
fo
rm
2
(4
.9
%
),
m
yc
et
om
a-
lik
e
2
(4
.9
%
),
er
ys
ip
el
oi
d
2
(4
.9
%
),
an
d
ch
an
cr
if
or
m
2
(4
.9
%
)
(2
3)
U
lB
ar
ia
n
d
R
az
a
[2
7]
20
06
–2
00
8
M
uz
aff
ar
ab
ad
,A
za
d
Ja
m
m
u
an
d
K
as
hm
ir
16
H
is
to
pa
th
ol
og
ic
al
ex
am
in
at
io
n
C
ut
an
eo
us
le
si
on
s
re
se
m
bl
in
g
lu
pu
s
vu
lg
ar
is
or
lu
pu
s
er
yt
he
m
at
os
us
,m
ai
n
ly
ov
er
fa
ce
.
M
or
ph
ol
og
ic
al
pa
tt
er
n
s
in
cl
ud
ed
er
yt
he
m
at
ou
s/
in
fi
lt
ra
te
d,
ps
or
ia
si
fo
rm
,u
lc
er
at
ed
/c
ru
st
ed
,
an
d
di
sc
oi
d
lu
pu
s
er
yt
he
m
at
os
us
†
A
s
n
ot
ed
,t
he
pr
ov
in
ce
of
B
al
oc
hi
st
an
fo
llo
w
ed
by
K
hy
be
r
Pa
kh
tu
n
kh
w
a
ap
pe
ar
s
to
ha
ve
ta
ke
n
a
m
aj
or
to
ll.
M
os
to
ft
he
ci
ti
es
an
d
ho
sp
it
al
s
w
he
re
th
e
di
se
as
e
ha
s
be
en
id
en
ti
fi
ed
se
rv
e
as
m
aj
or
te
rt
ia
ry
ca
re
re
fe
rr
al
ce
n
te
rs
fo
r
th
e
re
st
of
th
e
pr
ov
in
ce
.T
he
ex
ac
te
st
im
at
es
in
ad
jo
in
in
g
ci
ti
es
an
d
ru
ra
la
re
as
ar
e
un
de
re
st
im
at
ed
an
d
n
ot
w
el
lk
n
ow
n
.