Clinical Manifestations and Distribution of Cutaneous Leishmaniasis in Pakistan

Table 1

Summary of studies in Pakistan on clinical manifestations of Cutaneous Leishmaniasis alongside their geographic distribution.^†

		Period	City/province	Number of cases	Method of diagnosis	Species of Leishmania	Type of lesions seen
(1)	Gazozai et al. [8]	2005–2007	Quetta, Balochistan	300	Histopathological examination; skin smears		Nodules, plaques, ulcers and/or scarring
(2)	Firdous et al. [4]	2005–2007	Quetta, Balochistan; adjoining areas noted included Sibi, Zhob, Loralai, Pishin, and Kohlu	207	Histopathological examination	L. major	94% of lesions on upper and lower extremities in military personnel. 77(37%) had a single lesion, 46 (19%) had two lesions, 19(9%) had three lesions, and 35% had four lesions. The lesions were mostly noduloulcerative plaques with or without crusting
(3)	Kakarsulemankhel et al. [9]	1996–2001	Data from 7 zones of the province of Balochistan	School children: 17–22 years: 1617 cases; 11–16 years: 2643 cases 5–10 years: 3210 cases; 8,007 patients with active lesions presenting to hospitals/clinics.	Survey data, clinical and/or histopathological examination employed in different regions		Dry lesions more common in Quetta; wet lesions in other 6 regions of the province. Both active lesions and scarring were noted
(4)	Raja et al. [10]	1998	Balochistan	1709 patients; 2% (37) had unusual presentations	Clinical and histopathology		These included acute paronychial, chancriform, annular, palmoplantar, zosteriform, and erysipeloid forms in a total of 37 patients
(5)	Kassi et al. [1, 11]		Quetta, Balochistan	166	FNAC/Histopathology		Dry ulcerated lesions were noted to be more common on face, arms, and legs
(6)	Shoai et al. [12]	1997–2001	Karachi, Sindh (areas of origin of patients were noted from all 4 provinces, mainly from Sindh (40.5%) and Balochistan (28%))	175	Histopathological examination and PCR	Both L. Tropica and L. major	h 60 (82.6%) showed wet type of lesions characterized by exudates, redness, and inflamed margins. The remaining 15 (17.3%) were of dry and nodular type covered by crust
(7)	Brooker et al. [13]	2002-2003	19 neighboring villages in Balochistan and Khyber Pakhtunkhwa	7,305 persons	Clinical diagnosis		Overall, 650 persons (2.3%) had anthroponotic CL (ACL) lesions only, 1,236 (4.4%) had ACL scars only, and 38 persons had both ACL lesions and scars
(8)	Myint et al. [14]	2008	Samples from both Sindh and Balochistan: 48 cases from lowland areas; 21 cases from highland areas	69	Gene sequencing	47 L. Major and 1 L. Tropica in lowland areas.; 5 L. Major and 16 L. Tropica in highland areas.	Again, no correlation between clinical presentation (wet, dry and/or mixed types of cutaneous lesions) and causal leishmania parasites
(9)	Bhutto et al. [15]	1996–2001	Jacobabad, Larkana, and Dadu districts of Sindh province and residents of Balochistan province	1210	Clinical; a giemsa-stained smear test and histopathology		Clinically, the disease was classified as dry papular type, 407 cases; dry ulcerative type, 335 cases; wet ulcerative type, 18 cases
(10)	Bari et al. [7]	2009	Peshawar, Khyber Pakhtunkhwa	2	Slit skin smear and FNAC		Cutaneous fissures on lip and dorsum of finger
(11)	Rahman et al. [5]	2006–2008	Peshawar, Khyber Pakhtunkhwa	1680; 498 patients from different areas of Peshawar; 688 from FATA; 89 from other urban and rural areas of the province	Skin smear for LD bodies		Typical “oriental sore” noted in 1512 cases; 168 had an atypical presentation. Several chronic nonhealing ulcers were noted.
(12)	Ul Bari and Ejaz [6]	2009	Peshawar, Khyber Pakhtunkhwa	1	Skin smear preparation		Rhinophyma-like plaque on nose
(13)	Ul Bari [16]	2009	Peshawar, Khyber Pakhtunkhwa	72	Smear preparations/histopathological examination		Nasal leishmaniasis. Main morphological patterns included psoriasiform (30), furunculoid (8), nodular (13), lupoid (8), mucocutaneous (4), and rhinophymous (3)
(14)	Qureshi et al. [17]	2007	Abbottabad, Khyber Pakhtunkhwa	1	Histopathology		Typical butterfly-like rash seen in SLE
(15)	Saleem et al. [18]	2004–2006	Karachi, Sindh	100	Clinical and histopathological examination		Nodules, plaques, ulcers, crusted ulcers, lupoid lesions, and plaques with scarring were mainly noted
(16)	Bhutto et al. [19]	2009	Larkana, Sindh	108	Polymerase chain reaction (PCR)	L. Major (105) L. Tropica (3)
(17)	Ul Bari and Ber Rahman [20]	2004–2006	Punjab and Khyber Pakhtunkhwa	60	Slit-skin smear and histopathology		Presentation either (a) wet type (early ulcerative, rural) or (b) dry type (late ulcerative, urban)
(18)	Rowland et al. [21]	1997	Timergara, Dir, Khyber Pakhtunkhwa	9200 inhabitants	Clinical diagnosis; sample of cases confirmed with microscopy and PCR	Possible L. tropica based on Noyes et al. [22]	38% of the 9200 inhabitants bore active lesions, and a further 13% had scars from earlier attacks
(19)	Mujtaba and Khalid [23]	1995–1997	Multan, Punjab	305	Giemsa-stained smear from the lesion		All the lesions were of the dry type. Most of the lesions (97%) were present on exposed areas of the body
(20)	Ayub et al. [24]	1999–2000	Multan, Punjab	173	Smear for LD bodies		Clinically all the lesions were of dry type, with 67% present on legs
(21)	Anwar et al. [25]	2004	Khushab district, Punjab	105	FNAC of the lesion for first 4 cases; only history and clinical assessment for remaining		Disseminated forms noted in multiple cases; with 1 patient with more than 50 lesions
(22)	Bari and Rahman [26]	2002–2006	Rawalpindi, Sargodha, and Muzaffarabad	718 patients with CL; study was on 41 patients with unusual presentations	Clinical and histopathological examination		Common unusual presentations noted were lupoid leishmaniasis in 14 (34.1%), followed by sporotrichoid 5 (12.1%), paronychial 3 (7.3%), lid leishmaniasis 2 (4.9%), psoriasiform 2 (4.9%), mycetoma-like 2 (4.9%), erysipeloid 2 (4.9%), and chancriform 2 (4.9%)
(23)	Ul Bari and Raza [27]	2006–2008	Muzaffarabad, Azad Jammu and Kashmir	16	Histopathological examination		Cutaneous lesions resembling lupus vulgaris or lupus erythematosus, mainly over face. Morphological patterns included erythematous/infiltrated, psoriasiform, ulcerated/crusted, and discoid lupus erythematosus

^†As noted, the province of Balochistan followed by Khyber Pakhtunkhwa appears to have taken a major toll. Most of the cities and hospitals where the disease has been identified serve as major tertiary care referral centers for the rest of the province. The exact estimates in adjoining cities and rural areas are underestimated and not well known.