Clinical and demographic criteria for cutaneous leishmaniasis in Sirte, Libya

Aida A Abdel-Magied; Hala S Abou-El-Wafa; Abeer A El-Henawy

doi:10.4103/1687-7942.192994

ORIGINAL ARTICLE

Year : 2016 | Volume : 9 | Issue : 1 | Page : 18-23

Clinical and demographic criteria for cutaneous leishmaniasis in Sirte, Libya

Aida A Abdel-Magied¹, Hala S Abou-El-Wafa², Abeer A El-Henawy PhD ¹
¹ Department of Medical Parasitology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
² Department of Public Health & Community Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt

Date of Submission	17-Dec-2015
Date of Acceptance	15-Mar-2016
Date of Web Publication	25-Oct-2016

Correspondence Address:
Abeer A El-Henawy
Medical Parasitology department, Faculty of Medicine, Mansoura University, El-Gomhuria Street, PO Box 35516, Mansoura
Egypt

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1687-7942.192994

Abstract

Background
Cutaneous leishmaniasis (CL) comprises a major parasitic health problem worldwide, particularly in Libya where the prevalence of CL continues to re-emerge.
Objective
The aim of the present study was to determine the clinical patterns and demographic criteria of CL among cases with suspected skin lesions, prophylactically treated as a routine by intra-lesion injection of pentostam in the outpatient polyclinic in Sirte, Libya.
Participants and methods
This cross-sectional study was conducted on a total of 84 patients attending the dermatology clinic in the outpatient polyclinic at Sirte, Libya, during the period from March 2010 to January 2011; 40 (47.6%) females and 44 (52.4%) males. Age of the participants ranged from 12 to 40 years, with a mean age of 27±7.24 years. Cutaneous lesions were diagnosed microscopically by using the slit smear technique after staining with Giemsa stain for the amastigote forms of Leishmania spp.
Results
The infection rate was 63/84 (75%) among the studied group. Sex was significantly associated with acquisition of CL, with more males being at risk (60.3 vs. 39.7%; P=0.01). Occupation as a farmer posed a greater risk for infection (P=0.0004). Among the positive cases, the number of lesions ranged from three to five on lower limbs and were ulcerative in type (P=0.02, 0.01, and 0.0004, respectively).
Conclusion
Our results were in agreement with those of the previous studies about the prevalence of CL in Sirte, Libya. CL was found to be more common among male farmers, and most lesions were on the lower limb and were of the ulcerative type.

Keywords: cutaneous, epidemiology, leishmania spp, lesion, ulcer

How to cite this article:
Abdel-Magied AA, Abou-El-Wafa HS, El-Henawy AA. Clinical and demographic criteria for cutaneous leishmaniasis in Sirte, Libya. Parasitol United J 2016;9:18-23

How to cite this URL:
Abdel-Magied AA, Abou-El-Wafa HS, El-Henawy AA. Clinical and demographic criteria for cutaneous leishmaniasis in Sirte, Libya. Parasitol United J [serial online] 2016 [cited 2023 Mar 21];9:18-23. Available from: http://www.new.puj.eg.net/text.asp?2016/9/1/18/192994

Introduction

Leishmaniasis, one of the neglected tropical diseases, is ranked third in importance among vector-borne infections [1],[2]. The lack of reliable estimate rates due to its prevalence in poor impoverished countries and its defective appreciation by patients and physicians alike have added to the negligence shown toward it [2]. Libya is endemic for both visceral and cutaneous leishmaniasis (CL) [3],[4]. The wide spectrum of leishmaniasis, both in clinical presentation and severity of lesions, reflects its complex epidemiology [1].

CL is the most common form of leishmaniasis; an estimated 0.7 to 1.3 million new cases are reported worldwide annually [5]. It causes skin lesions ranging from nodules, papules to ulcers, with possible superimposed secondary bacterial infections and life-long scars with serious disability [1],[6]. Therefore, CL carries a significant social impact causing lifelong stigma for affected individuals [7]. Endemecity of CL in Libya is well-documented and the north-western areas of Libya are the most affected, where Leishmania major and tropica are the responsible species [8],[9].

In Libya, CL cases were reported in Nalut as well as in Tripoli, Al-Badarna, and Yafran areas [10],[11],[12],[13]. The diagnosis of CL in Libya is based mostly on clinical signs of the disease and the microscopic examination of the skin lesion sample [10],[11]. Libya lacks data on CL due to incomplete surveillance and under-reporting of the infection [14]. Therefore, the aim of the present study was to investigate the clinical patterns and demographic criteria associated with CL among cases with suspected skin lesions attending the outpatient polyclinic in Sirte, Libya.

Participants and methods

Study design

This cross-sectional study was conducted on patients with cutaneous lesions of various etiologies (n=304) attending the outpatient polyclinic in Sirte, Libya (the only referral unit in Sirte), during the period from March 2010 to January 2011. After initial evaluation, only cases with lesions suspected for CL (n=84) were included in the study − for example, cases with a history of exposure to arthropod bites, lesions on exposed parts, persistence of lesions, clinical presentation of lesions (nodules, papules, ulcers), or with ulcerative lesions surrounded by erythematous edematous borders and central necrosis.

Study area

Sirte is a Libyan coastal city that overlooks the Mediterranean Sea. It is located in the middle of the Libyan coast between Tripoli and Benghazi, 450 km to the east of the capital Tripoli ([Figure 1]); its estimated total population is 79 631.

Figure 1 Libya map showing Sirte location.

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Participants

Cases receiving systemic antileishmanial therapy before diagnosis were excluded from the study, in addition to cases with persistent lesions for more than 2 years and those classified as chronic CL. The skin and the mucous membrane of the mouth were carefully inspected to rule out the mucocutaneous type. Visceral leishmaniasis cases were excluded by careful general and abdominal examinations for lymphadenopathy and hepatosplenomegaly.

Methods

A questionnaire was designed to include demographic data (age, sex, residence, occupation, nationality, and family history). Clinical data of lesions (site, type, number, size, and treatment) were obtained either by clinical examination or from the medical records of patients or from responsible dermatologists. Due to lack of well-trained parasitologists for specific diagnosis, responsible dermatologists in the clinic adopted a type of diagnostic test-treatment strategy for all suspected cases of CL on the basis of history and clinical examination of the lesions. As the first-line treatment of CL in Libya is pentostam [14], all the studied patients had been treated with pentostam either alone or in combination with a dose of antibiotics in cases associated with evident bacterial infection. A routine intralesion injection of 1–3 ml of pentostam under the edges of the lesion until the total blanching of lesion for 5–7 days in a total of two to five times was given [15]. This strategy is well-documented in cases with visceral leishmaniasis and resorted to in endemic areas with poor resource settings, where clinicians bypass diagnostic testing and undergo treatment of every clinically suspected case [16].

Parasitological examination

The lesion was cleaned for debris with saline solution. Purulent or necrotic ulcers were treated with particular care, and debris was removed. The indurated active margin of the lesion was thoroughly cleaned with 70% alcohol. A sterile surgical blade was used to make a slit, 3 mm in length and 3 mm in depth, and the blood was cleaned by using sterile gauze. Once the bleeding had stopped, dermal tissue from the wall of the slit was scraped with a blade and smeared onto a glass slide. A total of three scrapings from the slit were smeared on a single slide. Smears were air dried, fixed with methanol, and Giemsa stained for 10 to 15 min and then washed with distilled water. The whole slide was examined with ×40 and then ×100 oil immersion objectives. All slides were examined by the same person, with no previous knowledge of the patients or of the sample registration code so as to avoid subjective interpretation of results. For patients exhibiting more than one lesion, a detailed examination of each lesion was performed to choose the site of sample extraction. Processing and examination of samples were carried out at the Microbiology Department laboratory in El Tahady University, Sirte.

Statistical analysis

Qualitative variables were described as numbers and percentages. Quantitative variables were described as mean±SD. The χ²-tests or Fisher’s exact tests was applied to analyze categorical variables, as appropriate. For comparison of continuous variables, the independent-sample-test was used. All reported values were two sided and were considered statistically significant at a P-value of less than or equal to 0.05. Data analyses were performed using the SPSS Statistics software (version 20.0; SPSS Inc., Chicago, Illinois, USA).

Ethical approval

An informed consent was obtained from all participants. The procedures carried out in this study were approved by the El Tahady University research committee, and adhered to the guidelines laid down by the Helsinki Declaration.

Results

A flow chart representing the step by step procedure of the study was drawn ([Figure 2]). A total of 84 patients − 40 (47.6%) females and 44 (52.4%) males − attending the outpatient polyclinic in Sirte, Libya, with lesions suspected for CL were enrolled in the study. Age of the participants ranged between 12 and 40 years, with a mean age of 27±7.24 years. As regards the demographic data, only sex (P=0.01) and occupation as a farmer (P=0.0004) were significantly associated with CL infection ([Table 1]). Such clinical criteria of lesions as being on the lower limb, of ulcerative type, and three to five in number were significantly associated with CL (P=0.02, 0.01, and 0.0004, respectively; [Table 2]). Among the positive patients, history of a higher number of injections was associated with a lower probability for positive smear as 44.5% had a history of two injections, 33.3% had a history of four injections, and 22.2% had a full treatment course ([Table 2]). As sex was the most significant demographic factor, clinical criteria were further stratified according to sex but no difference was observed between the two sexes ([Table 3]).

Figure 2 A flow diagram representing the procedure of the study.

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Table 1 Sociodemographic data of Leishmania spp. positive versus negative cases

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Table 2 Characteristics of lesions in Leishmania spp. positive versus negative cases

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Table 3 Characteristics of lesions in Leishmania spp. positive cases stratified by sex

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Discussion

CL is considered an endemic disease in Libya [17]. The endemicity of CL in the north-west areas of Libya has been clearly confirmed by several studies [14],[18]. Tripoli, Yafran, Djebel-Neffoafussa, Nalut regions, Al-Jabal Al-Gharbi [8],[12],[18] and Sirte [19] were the reported areas. Although southern areas reported a lower incidence [13], the cases there have increased and extended to the Tunisian border [20]. In Sirte, the site of the current study, a study by Fathy et al. [19] estimated an annual incidence of 0.95% for CL, which is equivalent to 756.5 cases according to the current population estimates (79631 inhabitants). The condition represents a diagnostic challenge because of the wide spectrum of lesions that may present with different severity, clinical appearance, or duration [1]. In the present study, we aimed at investigating the clinical patterns and epidemiological aspects associated with CL among suspected cases attending the outpatient polyclinic in Sirte, which is the only referral clinic for CL cases in this area. Our study was carried out under difficult circumstances due to its critical timing (during the Libyan civil war) and underdeveloped facility (very poor resource setting) lacking suitable equipment for more sophisticated and time-consuming techniques. Clinical exclusion of similar suspected diseases as leprosy, tuberculosis, and cancer allowed us to focus diagnosis on suspected cases only. Chronic nonhealing lesions on exposed skin in an endemic area with no response to antibiotics favors the probability of leishmaniasis [21],[22].

In addition, in context of achieving our aim to diagnose acute CL in suspected cases, we extended the exclusion to post-kala-azar lesions and the visceral type. There are documented cases of subclinical forms of visceral leishmaniasis, in which the first presentation may be post-kala-azar lesions with no history of visceral leishmaniasis [23],[24],[25]. Although this is rare in classical visceral leishmaniasis, but in some cases, especially in Africa, a primary granuloma appears on the skin before the onset of visceral leishmaniasis. Reports dating back to 1938 [26],[27] describe cases with skin lesions that later developed visceral leishmaniasis. Several other such reports have been published since then [28],[29]. Moreover, in Leishmania spp./HIV co-infection dissemination of Leishmania spp. to the skin was reported probably due to associated immunosuppression in such patients [30].

A total of 84 suspected CL cases with a mean age of 27.25±7.23 years were examined over a period of 9 months. All samples were examined by using the slit smears technique for amastigote forms of Leishmania spp. Samples were obtained only from those sites having the most indurated margins [22],[31] avoiding necrotic and/or purulent bases of lesions [6]. Accordingly, CL was diagnosed microscopically in 63/84 (75%) of cases, microscopy being the standard diagnostic approach on all health levels in endemic areas due to cost, unavailability, and complexity of other techniques. Under the forementioned conditions, Leishmania spp. culture was not performed because it is time-consuming and has a potential of giving unreliable results related to in vitro maintenance issues [1]. Apart from sex (higher in males) and occupation (as a farmer), no other demographic data were associated with increased risk for CL in this region. The former results are in line with those of other studies from Libya [8],[32] and Sri Lanka [33], which reported that males were commonly affected due to occupational exposure to infection. As regards the latter result, a confirmation that 80.9% of cases were farmers is similar to that of a previously published report [8] from Al-Jabal Al-Gharbi region in Libya, in which farm-related activities proved to be the most frequent occupations among CL cases.

Records of CL presentations differ from one country to another. The most common type of lesions in the present study was ulcerative (84%). In a Turkish study also, conducted in Salinurfia, ulcerative lesions were recorded as the most common type but comprised only 39.2% of the cases [34]. Differences have been recorded even within the same country: in Nalut District in Libya, Belal et al. [32] classified lesions mostly as noduloulcerative (76%), while papuloulcerative was third in order (6.7%). Regarding the site of lesions, as expected lower limbs were the most prevalent sites of infection for CL, which is in line with other reports [35]. However, in our study the involvement of the upper limb and face proved to be lower than mentioned in a report from Sirte, in which location of the CL lesions on legs, arms, and face was 66.8, 52.1, and 41.1%, respectively [19]. Furthermore, a previous study from the Nalut district, Libya, reported the lower limb as the least affected site (6.7%) [32]. The distribution differences of CL lesions can be explained by the habits of the population, exposing certain parts of the body during sleeping to sand fly bites at night. It is worthwhile to note that after a full treatment course with prophylactic intralesion pentostam, 22.2% of the patients still had positive smear. Thus perhaps in the future, increasing the number or dosage of injections would improve the results.

Conclusion

Our study stressed the prevalence of CL in Sirte province in Libya. The ulcerative type was the most common and the most common sites were the lower limbs due to extended possibility of exposures, especially in farmers. A future report on the CL situation after the political disturbances in Libya and the advent of several foreign nationalities will be timely and helpful. Spread of rodents from disrupted burrows and stray dogs, and the spread of Phlebotomine species will probably change the vital statistics in the whole country. Protocols for the proper diagnosis of CL, its management, and control are a priority in the future for this region.

Authors contributions

AA Abdel-Megied designed the study and examined the samples; AA Abdel-Megied and AA El-Henawy contributed to the analysis of the cases; HS Abou-El-Wafa carried out statistical analysis; AA El-Henawy wrote the manuscript in cooperation with AA Abdel-Megied and all authors revised the final version and approved it.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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