Siriwardana Yamuna, Deepachandi Bhagya, Gunasekara Chalukya, Warnasooriya Wipula, Karunaweera Nadira D
Department of Parasitology, Faculty of Medicine, University of Colombo, Colombo 00800, Sri Lanka.
National Hospital, Colombo 00800, Sri Lanka.
J Trop Med. 2019 May 27;2019:4538597. doi: 10.1155/2019/4538597. eCollection 2019.
Sri Lanka is a recent focus having induced cutaneous leishmaniasis (CL) as the main clinical entity. A separate clinical entity within profile of CL was described in this study. Laboratory confirmed cases of CL (n= 950, 2002-2014) were analysed. Most lesions showed known classical developmental stages of CL (CCL) observed in other CL endemic settings while few cases (13%, 122/950) showed atypical skin manifestations (ACL). Clinical, geographical, and treatment response patterns of ACL were different from those of CCL. ACL was mainly found among males (68.0%), in 21-40 year age group (51.6%), and reported delayed treatment seeking (23.5% vs 16.3% in CCL), more nonclassical onset (lesions other than acne form <1cm sized papules), (12.1 vs 2.7%, P<0.05.), more head and neck lesions (41.5%. vs 27.2%), more large lesions (>4cm), (18.6 vs 9.9%), and poor laboratory positivity rates (65.6% vs 88.2%) when compared to CCL. When compared to lesions reporting a typical onset, lesions reporting nonclassical onset were more likely to develop ACL later on (50.1% vs 10.7%). As compared to lesions on limbs, those on head and neck and trunk were more likely to be ACL (7.0%, 16.3%, and 22.8%, respectively, P<0.05). ACL features were not age or gender dependent. Highest proportion within ACL category (32.8%) and small proportion of CCL (10.1%) originated from less leishmaniasis prevalent areas (other regions) (P<0.05). North reported more ACL than South (15.9% vs 7.4%). A total of 95 CL cases with a significant travel history were further analyzed. Residents of other regions when acquired infection from North or South developed more ACL than residents in North or South (60.9% vs 15.9% and 42.9% vs 7.4% respectively). Patients in other regions when travelled to North developed more ACL than when they travelled to South (60.9%, 42.9%). ACL and CCL required an average of 18 doses over 16.7 months and 10 doses over 12 weeks, respectively, to achieve a complete clinical cure. Underlying host immunological factors, parasite strain variations and regional variations of both could be underlying etiologies. Established independent transmission within less leishmaniasis prevalent regions combined with an unusual clinical picture leading to poor clinical suspicion and low laboratory confirmation rate will pose potential difficulties in early case detection in these highly populated and commercialized areas. This in turn will further facilitate silent and high disease transmission.
斯里兰卡是近期的一个研究重点，其主要临床病症为皮肤利什曼病（CL）。本研究描述了CL病例中的一种独特临床类型。对实验室确诊的CL病例（n = 950，2002 - 2014年）进行了分析。大多数皮损呈现出在其他CL流行地区所观察到的已知经典发展阶段（CCL），而少数病例（13%，122/950）表现出非典型皮肤表现（ACL）。ACL的临床、地理和治疗反应模式与CCL不同。ACL主要见于男性（68.0%），年龄在21 - 40岁组（51.6%），且报告有延迟就医情况（23.5%，而CCL为16.3%），更多非典型发病情况（除痤疮样<1cm大小丘疹外的皮损）（12.1%对2.7%，P<0.05），更多头颈部皮损（41.5%对27.2%），更多大皮损（>4cm）（18.6%对9.9%），与CCL相比实验室阳性率较低（65.6%对88.2%）。与报告典型发病的皮损相比，报告非典型发病的皮损随后更易发展为ACL（50.1%对10.7%）。与四肢皮损相比，头颈部和躯干的皮损更易为ACL（分别为7.0%、16.3%和22.8%，P<0.05）。ACL特征与年龄或性别无关。ACL类别中最高比例（32.8%）以及CCL中的小比例（10.1%）源自利什曼病流行程度较低的地区（其他地区）（P<0.05）。北部报告的ACL比南部多（15.9%对7.4%）。对95例有显著旅行史的CL病例进行了进一步分析。其他地区的居民从北部或南部感染时，比北部或南部的居民发展为ACL的更多（分别为60.9%对15.9%和42.9%对7.4%）。其他地区的患者前往北部时比前往南部时发展为ACL的更多（60.9%，42.9%）。ACL和CCL分别平均需要在16.7个月内注射18剂和在12周内注射10剂才能实现完全临床治愈。潜在的病因可能是宿主潜在的免疫因素、寄生虫菌株变异以及两者的区域差异。在利什曼病流行程度较低的地区存在独立传播，再加上不寻常的临床症状导致临床怀疑不足和实验室确诊率低，这将给这些人口密集和商业化地区的早期病例检测带来潜在困难。这反过来又将进一步促使疾病隐匿且高效传播。
