Post-kala-azar dermal leishmaniasis in the Indian subcontinent: A threat to the South-East Asia Region Kala-azar Elimination Programme (original) (raw)
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Parasites & Vectors, 2013
Post kala-azar dermal leishmaniasis (PKDL) is a neglected complication of visceral leishmaniasis (VL)―a deadly, infectious disease that claims approximately 20,000 to 40,000 lives every year. PKDL is thought to be a reservoir for transmission of VL, thus, adequate control of PKDL plays a key role in the ongoing effort to eliminate VL. Over the past few years, several expert meetings have recommended that a greater focus on PKDL was needed, especially in South Asia. This report summarizes the Post Kala-Azar Dermal Leishmaniasis Consortium Meeting held in New Delhi, India, 27–29 June 2012. The PKDL Consortium is committed to promote and facilitate activities that lead to better understanding of all aspects of PKDL that are needed for improved clinical management and to achieve control of PKDL and VL. Fifty clinicians, scientists, policy makers, and advocates came together to discuss issues relating to PKDL epidemiology, diagnosis, pathogenesis, clinical presentation, treatment, and co...
American Journal of Tropical Medicine and Hygiene, 2012
Post-kala-azar dermal leishmaniasis (PKDL) has important public health implications for transmission of visceral leishmaniasis (VL). Clinical and epidemiologic profiles of 102 PKDL patients showed that median age of males and females at the time of diagnosis was significantly different (P = 0.013). A significant association was observed between family history of VL and sex of PKDL patients (χ 2 = 5.72, P 0.01). Nearly 33% of the patients showed development of PKDL within one year of VL treatment. The observed time (median = 12 months) between appearance of lesions and diagnosis is an important factor in VL transmission. A significant association was observed between type of lesions and duration of appearance after VL treatment (χ 2 = 6.59, P = 0.001). Because PKDL was observed during treatment with all currently used anti-leishmanial drugs, new drug regimens having high cure rates and potential to lower the PKDL incidence need to be investigated.
Clinical Infectious Diseases, 2010
On the basis of active case finding among 22,699 respondents, 813 (3.6%) had had kala-azar since 2002, of whom 79 (9.7%) developed PKDL. Eight additional patients with PKDL had no history of kala-azar. Annual kala-azar incidence peaked at 85 cases per 10,000 person-years in 2004 and fell to 46 cases per 10,000 person-years in 2007, but PKDL incidence rose from 1 case per 10,000 person-years in 2002-2004 to 21 cases per 10,000 person-years in 2007. The rising PKDL incidence threatens the regional visceral leishmaniasis elimination initiative and underscores the urgent need for more effective PKDL diagnosis and treatment.
Transactions of the Royal Society of Tropical Medicine and Hygiene, 2011
A cohort of 91 asymptomatic individuals with visceral leishmaniasis (VL) were identified during base line screening using recombinant 39-aminoacid antigen (rk-39) and polymerase chain reaction (PCR) conducted from December 2005 to June 2006 involving 997 individuals of two highly endemic villages of Vaishali district, Bihar. The point prevalence of asymptomatic infection was 98 per 1000 persons at baseline. There was no statistically significant difference between rk-39 and PCR positivity rate (P > 0.05), even though PCR positivity alone was found significantly higher (4.2%) than rk-39 positivity alone (2.6%). The monthly follow-up of the asymptomatic cohort revealed a disease conversion rate of 23.1 per 100 persons within a year. There was a statistically significant difference in conversion of disease when individuals were positive by both tests as compared to single tests by rk-39 and PCR (P < 0.01). Disease conversion rate in the subjects residing in households with a history of VL (62%, 13/21) was higher than those residing in the households without a history of VL (38%, 8/21). Most of the identified asymptomatic individuals were from low socioeconomic strata similar to that of VL cases in general. Apart from rk-39, PCR may be considered for screening of asymptomatic Leishmania donovani infection in large-scale epidemiological studies. Screening of asymptomatic cases and their close follow-up to ascertain early detection and treatment of VL may be considered in addition to the existing VL control strategies.
Challenges for management of post kala-azar dermal leishmaniasis and future directions
Research and Reports in Tropical Medicine, 2014
Post kala-azar dermal leishmaniasis (PKDL) is a skin complication resulting from infection with Leishmania donovani (LD) parasite. It mostly affects individuals who have previously suffered from visceral leishmaniasis (VL) caused by LD. In some cases, PKDL develops among people infected with LD, but do not show any symptoms of VL. Clinical presentation includes hypopigmented macules/papules/nodules or polymorphic lesions (combination of two or more lesions). Except for skin lesions, PKDL patients are generally healthy and usually do not seek medical care. These patients play an important role in interepidemic transmission of the infection and subsequent VL outbreak. Therefore, proper diagnosis and treatment of PKDL patients is important for the control of VL in endemic countries, especially in the Indian subcontinent where VL is anthroponotic. Here, we report the challenges in the estimation of PKDL burden, its diagnosis, and treatment, and suggest possible solutions based on recent literature, reports, published manuals, and web-based information.
Tropical Medicine & International Health, 2012
We assessed the prevalence of post-kala-azar dermal leishmaniasis (PKDL), a late cutaneous manifestation of visceral leishmaniasis (VL), in 16 VL-endemic communities in Bihar, India. The prevalence of confirmed PKDL cases was 4.4 per 10 000 individuals and 7.8 if probable cases were also considered. The clinical history and treatment of the post-kala-azar dermal leishmaniasis cases are discussed.
Post kala-azar dermal leishmaniasis: A threat to elimination program
PLOS Neglected Tropical Diseases, 2020
Leishmaniasis remains a public health concern around the world that primarily affects poor folks of the developing world spanning across 98 countries with mortality of 0.2 million to 0.4 million annually. Post kala-azar dermal leishmaniasis (PKDL) is the late skin manifestation of visceral leishmaniasis (VL). It has been reported that about 2.5% to 20% of patients recovered from VL develop PKDL having stilted macular or nodular lesions with parasites. In the Indian subcontinent (ISC), it manifests a few months after recovery from VL, though in Africa it can occur simultaneously with VL or a little later. New cases of PKDL are also observed without prior VL in the ISC. These individuals with PKDL represent an important but largely neglected reservoir of infection that perpetuates anthroponotic Leishmania donovani transmission in the ISC and can jeopardize the VL elimination program as these cases can infect the sand flies and spread the endemic. Therefore, it becomes imperative to eradicate PKDL as a part of the VL elimination program. With the limited treatment options besides little knowledge on PKDL, this review stands out in focusing on different aspects that should be dealt for sustained VL elimination.
Asymptomatic leishmaniasis in kala-azar endemic areas of Malda district, West Bengal, India
PLOS Neglected Tropical Diseases, 2017
Asymptomatic leishmaniasis may drive the epidemic and an important challenge to reach the goal of joint Visceral Leishmaniasis (VL) elimination initiative taken by three Asian countries. The role of these asymptomatic carriers in disease transmission, prognosis at individual level and rate of transformation to symptomatic VL/Post Kala-azar Dermal Leishmaniasis (PKDL) needs to be evaluated. Asymptomatic cases were diagnosed by active mass survey in eight tribal villages by detecting antileishmanial antibody using rK39 based rapid diagnostic kits and followed up for three years to observe the pattern of sero-conversion and disease transformation. Out of 2890 total population, 2603 were screened. Antileishmanial antibody was detected in 185 individuals of them 96 had a history of VL/PKDL and 89 without such history. Seventy nine such individuals were classified as asymptomatic leishmaniasis and ten as active VL with a ratio of 7.9:1. Out of 79 asymptomatic cases 2 were lost to follow up as they moved to other places. Amongst asymptomatically infected persons, disease transformation in 8/77 (10.39%) and sero-conversion in 62/77 (80.52%) cases were noted. Seven (9.09%) remained sero-positive even after three years. Progression to clinical disease among asymptomatic individuals was taking place at any time up to three years after the baseline survey. If there are no VL /PKDL cases for two or more years, it does not mean that the area is free from leishmaniasis as symptomatic VL or PKDL may appear even after three years, if there are such asymptomatic cases. So, asymptomatic infected individuals need much attention for VL elimination programme that has been initiated by three adjoining endemic countries.
Overview of Leishmaniasis with Special Emphasis on Kala-azar in South Asia
Neglected tropical diseases, 2017
Abbreviations AVL Anthroponotic visceral leishmaniasis CL Cutaneous leishmaniasis DALY Disability-adjusted life year IRS Insecticide residue spread MCL Mucocutaneous leishmaniasis NTD Neglected tropical diseases PKDL Post-kala-azar dermal leishmaniasis PV Parasite-containing vacuole rK39 Recombinant kinesin 39 amino acid repeats rKE16 Recombinant kinesin antigen from L. donovani VL Visceral leishmaniasis ZCL Zoonotic cutaneous leishmaniasis 1 Global Overview of Leishmaniasis 1.1 Disease Types Leishmaniasis is a complex disease caused by Leishmania infection, producing variable clinical symptoms, e.g., cutaneous, mucocutaneous, and visceral leishmaniases [1-3]. Cutaneous leishmaniasis (CL) caused, for example, by Leishmania major/L. tropica is marked by the appearance of skin lesion in various forms, which are often innocuous and self-healing, while mucocutaneous leishmaniasis (MCL) caused, for example, by L. braziliensis is a protracted disease, resulting sometimes in facial disfigurement of the ear, mouth, and nose. Neither CL nor MCL is lifethreatening per se. Only in non-healing case has death of these patients been reported due to secondary infections or other causes, e.g., suicide as a result of unbearable psychological stress. Visceral leishmaniasis (VL) caused by L. donovani/L. infantum is far more severe. It is often fatal, if untreated, resulting from systemic and progressive infection of macrophages by Leishmania in the reticuloendothelial systems or lymphoid organs, chiefly the spleen, liver, and bone marrow. Disorders of hematological and hepatosplenic functions are thus the clinical manifestations of VL, including hepatosplenomegaly, fever, anemia, leucopenia, hypergammaglobulinemia, and cachexia. The development of all leishmaniases follows a chronic course lasting for months and sometimes years. A vibrant and active biomedical research community has long existed in India, under the aegis of both national and international organizations, for basic, clinical, and other researches of kala-azar. There are internationally sought-after kala-azar clinics in the well-established endemic sites, drug/vaccine production facilities, and many kala-azar research laboratories. Nowhere else in the world can one find another country, except perhaps Brazil, to match India in the scale of dedication, devotion, and contribution to kala-azar research. Given below are examples of some Indian institutions and recent kala-azar research to illustrate the points. 4.1 Indian Institutions with Kala-azar Research Components Some Indian government agencies, which provide administrative and financial support: