CME INDIA Case Presentation by Dr Bhanu Pratap Singh, MD, Medicine, Siwan, Bihar.

CME INDIA Case Study

CASE: This patient presented with nodular rashes of 3-4 months duration, non-itching, mainly centrifugal distribution, no other systemic findings at present. Past H/O Kala-azar, 8 yrs back, treated with amphotericin B. What is Probable Diagnosis. Skin smear test asked.

CME INDIA Discussion:

Dr Omprakash, Jamui, Bihar:  PKDL

Dr Amit Kumar, Dermatologist, Ranchi: Any pics of trunk and back

Dr Bhanu Pratap Singh: Sir, could not take it, but searched for the same, hardly 4 -5 nodules were there on the trunk and back.

Dr S K Goenka, Begusarai, Bihar: PKDL patients are the most important carriers of Kala-azar. These skin lesions are misdiagnosed and the V.leishmania remains in the society. Miltefosin (50mg) 1×3 for 28 days is advocated.

Dr Bhanu Pratap Singh: Miltefosin is not available now sir even in district hospitals.

Dr Amit Kumar, Dermatologist, Ranchi: Nerve palpation findings?

Dr Bhanu Pratap Singh: No nerve tenderness, though I palpated only posterior tibial only.

Dr Amit Kumar, Dermatologist, Ranchi: PKDL is the first diagnosis seeing the papules and previous history of VL. However, the forehead has diffuse infiltration and plaque hence need to rule out Hansen’s also.

Dr Ravishankar Dwivedi, Dermatologist, Ranchi: PKDL. Please go for biopsy. More helpful than smear. Miltefocin firstline drug of choice.

Dr Bhuna Pratap Singh: Skin Slit Smear Exam for L.D.Bodies shows:

nodular rashes

CME INDIA Learning Points:

  • Post-kala-azar dermal leishmaniasis(PKDL) follows the treatment of visceral leishmaniasis and has predominantly been described in India (about 10% of cases).
  • The Indian variant occurs in patients 1-2 years and as long as 20 years after recovery from visceral leishmaniasis . This condition is characterized by multiple, hypopigmented, erythematous macules. Over time, these macules can transform into large nontender plaques and nodules that involve the face and trunk.
  • These individuals with PKDL represent an important but largely neglected reservoir of infection that perpetuates anthroponotic Leishmania donovani transmission.
  • Even today, primary diagnosis of PKDL mainly relies on clinical assessments, including the history of VL, typical skin lesions, evidence of past VL by antileishmanial antibody, and exclusion of skin fungal disorders and leprosy. 
  • Diagnosis of PKDL through histopathology uses hematoxylin and eosin (H&E) staining for the demonstration of LDBs in skin specimens and is considered as a gold standard. However, the degree of positivity for LDBs varies from 67% to 100% in nodular lesions, 36% to 69% in papular lesions and 7% to 33% in macular lesions. Real-time PCR or qPCR allows detection and quantification of the parasite number.
  • Presently, PKDL patients in the Indian subcontinent are treated with 50 mg miltefosine (for 12 weeks, twice a day); longer treatment duration (up to 16 weeks) led to improved cure rates of 96% to 100%, but many gastrointestinal side effects posed the hurdle.
  • The therapeutic regimen currently adopted for PKDL treatment requires long treatment durations and adherence for four to 12 months for a full recovery.

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