Cutaneous leishmaniasis or “Kal Dana” (“the year-long sore”), as it is known locally, not only leaves a disfiguring scar on your face, but permanently changes your perception of your own self (Figure 1). “This is not me,” said the woman from Chaman, as she explained her encounter with the disease and the stigmatization associated with it.



Figure 1

Marring leishmaniasis with lesions on exposed parts of the face.



This 28-year-old woman is a resident of Chaman, a town located near the Pakistan–Afghanistan border, in the southwestern province of Balochistan. For decades, Chaman has been a hub for refugees crossing the Durand line; it also is one of the many regions where poverty and lack of health resources show their true victimization of refugees. One such case is that of this woman.

She belonged to a poor family; her father, the sole breadwinner of the family, is a cattle rearer. She acquired her first lesion at the age of 12; from thereon she was socially excluded and not allowed to go to the local madrassah (an Islamic religious school). As she grew older, multiple other lesions appeared on her arms and face (the exposed parts of the body). She described this as a period of grief for her, when her parents started isolating her from the rest of the siblings to prevent further spread.

No treatment was acquired, due to the afflicting poverty and lack of resources of the region. But the scar had a deeper impact on this woman, as she is still unmarried in a community where early marriages are common. She describes her fate as, “I will probably get married to a limp or mentally disabled in a year or so; at least that is what happened to all the other girls who had these marks.”

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Marring leishmaniasis: the stigmatization and the impact of cutaneous leishmaniasis in Pakistan and Afghanistan.

Pakistan is ranked 9th in terms of flood-affected countries worldwide. In the summer of 2010, the northern province of Khyber-Pakhtunkhwa received more than 312 mm of rain in a 56 hour period. This resulted in over 1 600 deaths across the region. In addition, over 14 million people were directly affected by this record-breaking deluge. Flood affected regions serve as ideal breeding grounds for pathogens, leading to the spread of diseases. The poor standards of hygiene in camps set up for individuals displaced by the floods also contribute to this. It is essential that those involved in relief efforts are aware of the epidemiology of diseases that have historically seen a sudden upsurge after natural disasters. Keeping this in mind, we conducted a simple review of literature. An extensive literature search was conducted using the PubMed data base and online search engines. Articles published in the last 20 years were considered along with some historical articles where a background was required. Seven major diseases were identified to increase substantially in the aftermath of natural disasters. They were then classified into acute and sub-acute settings. Diarrhea, skin & eye infections and leptospirosis were identified in the acute setting while malaria, leishmaniasis, respiratory infections and hepatitis were identified in the sub-acute setting.

Infectious diseases in the aftermath of monsoon flooding in Pakistan

Leishmania tropica and Leishmania major are both the main cause of anthroponotic (ACL) and zoonotic cutaneous leishmaniasis (ZCL), respectively, in the Old World. Leishmania infantum and Leishmania donovani, which are important causes of visceral leishmaniasis, have also occasionally been reported in CL patients. The present study investigates the current distribution of causative species of CL in Iran and neighboring countries in the Middle East. There has been expansion of L. tropica into new urban and rural foci in Iran, with well-documented cases of visceralization, a substantial increase of CL in Syria, and the emergence of new foci and outbreaks in Turkey and Iraq, especially due to L. major. Civil war in Syria and Iraq, population movement, poverty, and climatic change play important roles in the changing CL distribution in this region. Control programs should adopt a multidisciplinary approach based on active surveillance and case finding, especially in vulnerable refugee populations, determination of hazard maps for CL hot points using GIS and other advanced technology, the free distribution of drugs, rodent control, and greater community engagement in poor and marginalized populations. Comprehensive molecular studies that could show the species and strains of Leishmania in different areas of each country can give a better view from the distribution of CL in this region.

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The Geographical Distribution of Cutaneous Leishmaniasis Causative Agents in Iran and Its Neighboring Countries, A Review

Background & objectives: Cutaneous leishmaniasis (CL) has been recently emerged in new foci, posing a public health problem. Increasing cases of CL have been reported during recent years from a border area between Iran and Pakistan, a previously non-endemic area. The present study was designed for epidemiological and parasitological characterization of the disease for the first time in this area. Methods: A total of 3100 individuals from the city of Mirjaveh and its four rural districts were randomly selected and surveyed from March 2005 to February 2006. Microscopic examination, in vitro culture, mouse inoculations and species-specific kDNA-PCR assay were carried out for Leishmania detection and species identification. Results: CL was endemic in an important rural district of Mirjaveh, presenting active lesions and scars in 6.6 and 9.5%, respectively. The highest rates of both active lesions and scars were found in the age group of 10 years or under with significant differences (p 0.05). The most affected location was upper limb, 39.2% of ulcers and 41.7% of scars. Inoculation of the clinical isolates on Balb/c mice, led to the development of ulcers in the animals, implying that the causative parasite is Leishmania major. The PCR amplification also generated amplicons specific to L. major. Conclusion: It can be concluded that Mirjaveh is an endemic region of cutaneous leishmaniasis as a new focus due to the recent emergence in this border area of south-east of Iran with a major contribution of L. major, as the causative parasite species.

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Emergence of cutaneous leishmaniasis in a border area at south-east of Iran: an epidemiological survey.

Cloning, expression, and purification of a novel recombinant antigen from Leishmania donovani.

Background Cutaneous leishmaniasis (CL) is endemic in Pakistan and is widely spreading. Recently, an outbreak of the disease was observed in the region. We report some new endemic areas of CL in the country.



Methods A total of 1210 cases of CL who visited our department from 1996 to 2001 are reported. Among them, 760 were residents of the Jacobabad, Larkana, and Dadu districts of Sindh province and had never previously traveled to endemic areas. These districts have never been reported/recognized as endemic for CL. Others were residents of endemic areas of Balochistan province. Diagnosis was made on clinical presentation; a giemsa-stained smear test and histopathological results. All the cases were treated with the meglumine antimoniate 600 mg/day (adults) and 15 mg/kg/day (children) intramuscularly for 20 consecutive days.



Results All the patients were aged between 2.5 months and 65 years. Three hundred and ninety-two patients were females and 368 were males. Duration of the disease ranged from 2 to 18 months. Most of the patients had a single lesion on the face and/or extremities. Clinically, the disease was classified as: dry papular type, 407 cases; dry ulcerative type, 335 cases; and wet ulcerative type, 18 cases. No cases of muco-cutaneous or visceral leishmaniasis were found during this period. Smear testing was positive in 845 cases, while 365 cases were histopathologically positive. An ultrastructural study was performed using specimens of a few of the cases. Leishmania parasites were detected in the dermal tissues as well as in the macrophages.



Conclusions We propose that the Jacobabad, Larkana and Dadu districts could be considered endemic for CL. Wet- and dry-type lesions indicate the presence of both Leishmania tropica and L. major in this tropical region.

Rashid A. Soomro

Papers

Detection of new endemic areas of cutaneous leishmaniasis in Pakistan: a 6-year study.