CME INDIA Case Presentation by Dr. Ravishankar Dwivedi, MBBS, MD – Dermatology, Ranchi.
CME INDIA Case Study
- A 36 yr-old-male from Godda district, Jharkhand, presented with asymptomatic papulo nodular lesion appearing on the lips for three years gradually increasing in number and size.
- No other relevant present clinical complaints or signs.
- All routine blood investigations, Mantoux, Xray chest P/a, Serum ACE levels all normal.
- Hint: Godda district, Tribal belt, 3 yr. duration, Asymptomatic.
CME INDIA Discussion (30/03/2022)
Dr. Sunil Kumar Sinha, Dhanbad:
- Leishmaniasis (cutaneous)
Dr. S. K. Goenka, Begusarai:
- HD
Dr. R. K. Gupta, Yamuna Nagar:
- Lepromatous Leprosy
Dr. R. R. Baranwal, Giridih:
- Leishmaniasis
Dr. Sagar Subhash More, Nashik:
- Post kala Azar Dermal Leishmaniasis (PKDL)
Dr. Ravishankar Dwivedi, Ranchi:
- Thanks for all the inputs.
- So, on basis of clinical findings primary d/d was
| PKDL |
| Hansen’s |
| Cutaneous T-cell lymphoma (CTCL), Pseudo lymphoma, |
| Sarcoidosis |
Biopsy Shows:
Biopsy of a papule showing follicular plugging and a dense lymphohistiocytic infiltrate in the top half of dermis
- Biopsy findings points towards PKDL. Perimuzzle papulo nodular lesion in patients from endemic area is almost diagnostic of PKDL.
- On further probing, patient gave history of VL 10 yrs. back with incomplete treatment with inj stibogluconate.
- Papulonodular lesions are a big reservoir of infection and has potential to spread the disease in a big way, hence need for high index of suspicion and urgent reporting to authorities.
- Treatment of choice Miltefocin 50mg twice daily for 84 days. Not available in market. Trying to get it from WHO authorities. Endemic district has vector born disease control program and provide free medication for the same.
Dr. S. K. Goenka, Begusarai:
- I could not spot the LD bodies in the peripheral smear.
Dr. Amit Kumar, Ranchi:
- There are dense eosinophilic and neutrophilic infiltrate with few giant cells…
- LD bodies are seen in special staining i.e., Giemsa stain.
Quick Take Away
- PKDL caused by L. donovani.
- It is an assorted dermatologic complication following apparent treatment of visceral leishmaniasis (VL).
- It assumes significance as a major reservoir in inter-epidemic transmission of VL that could be possible through anthroponotic route.
- PKDL case has also been reported without any previous history of VL.
- It clinically manifested with macular (hypo-pigmented patches), papulo-nodular lesions or polymorphic skin lesions.
CME INDIA Learning Points
Post kala-azar dermal leishmaniasis (PKDL)
- It is a cutaneous sequela of visceral leishmaniasis (VL).
- It develops in some patients alongside but more commonly after apparent cure from VL.
- In 15-20% of the cases there is no previous history of visceral leishmaniasis but these patients invariably hailed from the kala azar endemic region.
- It has got pivotal role in the transmission of VL.
- Post kala azar dermal leishmaniasis is clinically characterized by hypopigmented macules and erythematous papules, plaques and nodules.
- The clinical presentation of VL patients suffer from prolonged fever, hepatosplenomegaly, weight loss and anaemia.
- The manifestations of PKDL are limited to macular, papular, or nodular lesions in the skin.
- PKDL is usually confined to two geographically distinct zones, 1. South Asia (India, Nepal, and Bangladesh) 2. East Africa, mainly Sudan.
- South Asian variant: Polymorphic lesions (coexistence of macules/patches along with papulonodules) prevalent, Sudanese variant: Papular or nodular lesions.
- It has been observed that lesions of PKDL consistently appear on sun-exposed areas, particularly the face, ears, arms, etc., rather than unexposed areas, such as the scalp and chest.
- It appears that exposure to UV light plays a contributory role in the pathogenesis of PKDL.
- There is no standard guideline for diagnosis and treatment for PKDL.
- Confirmation of diagnosis is difficult and microscopic demonstration of Leishman-Donovan bodies from skin lesions has low sensitivity.
- The PCR-based molecular diagnostic method is anticipated to provide a powerful approach.
- It must be appreciated that various histomorphological patterns of post kala azar dermal leishmaniasis are a useful clue to the diagnosis. It provides diagnosis even when LD bodies have not been detected.
- Miltefosine (MF) is the only oral drug existing for treatment of post-kala-azar dermal leishmaniasis (PKDL).
- Increased miltefosine tolerance in clinical isolates of Leishmania donovani has been reported.
CME INDIA Tail Piece
References:
- Mukhopadhyay D, Dalton JE, Kaye PM, Chatterjee M. Post kala-azar dermal leishmaniasis: an unresolved mystery. Trends Parasitol. 2014;30(2):65-74. doi:10.1016/j.pt.2013.12.004
- Ganguly S, Saha P, Chatterjee M, et al. PKDL–A Silent Parasite Pool for Transmission of Leishmaniasis in Kala-azar Endemic Areas of Malda District, West Bengal, India. PLoS Negl Trop Dis. 2015;9(10):e0004138. Published 2015 Oct 20. doi:10.1371/journal.pntd.0004138
- Brahmachari UN. A New Form of Cutaneous Leishmaniasis-Dermal Leishmanoid. Ind Med Gaz. 1922;57(4):125-127.
- Mukherjee A, Ramesh V, Mishra RS. Post kala azar dermal leishmaniasis: A light and electron microscopic study of 18 cases. J Cutan Pathol 1993; 20:320-5.
- Topno RK, Rabi Das VN, Kumar M, Madhukar M, Pandey K, Verma N, et al. (2020) Advanced case of PKDL due to delayed treatment: A rare case report. PLoS Negl Trop Dis 14(3): e0008052. https://doi.org/10.1371/journal.pntd.0008052
- Verma N, Singh D, Pandey K, Das VN, Lal CS, Verma RB, Sinha PK, Das P (2013) Comparative evaluation of PCR and imprint smear microscopy analyses of skin biopsy specimens in diagnosis of macular, Papular, and mixed Papulo-nodular lesions of post-Kala-Azar dermal Leishmaniasis. J Clin Microbiol 51(12):4217–4219. pmid:24068017
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