Old World cutaneous leishmaniasis treatment response varies depending on parasite species, geographical location and development of secondary infection

Waleed S Al-Salem,Mohamed H Alzahrani,Zeyad Alzeyadi,Abdullah M Assiri,Ziad Memish,Aitor Casas-Sánchez,Naomi A Dyer,Gareth D Weedall,Ali M Al-Shahrani,Carla Solórzano,Khalid S Alsohibany,Álvaro Acosta-Serrano,Yasser Alraey,Louise Kelly-Hope,Salah M Balghonaim,Alice Halliday,Essam J Alyamani

doi:10.1186/s13071-019-3453-4

Abstract

BackgroundIn the Kingdom of Saudi Arabia (KSA), Leishmania major and L. tropica are the main causative agents of Old World cutaneous leishmaniasis (CL). The national CL treatment regimen consists of topical 1% clotrimazole/2% fusidic acid cream followed by 1–2 courses of intralesional sodium stibogluconate (SSG); however, treatment efficacy is highly variable and the reasons for this are not well understood. In this study, we present a complete epidemiological map of CL and determined the efficacy of the standard CL treatment regime in several endemic regions of KSA.ResultsOverall, three quarters of patients in all CL-endemic areas studied responded satisfactorily to the current treatment regime, with the remaining requiring only an extra course of SSG. The majority of unresponsive cases were infected with L. tropica. Furthermore, the development of secondary infections (SI) around or within the CL lesion significantly favoured the treatment response of L. major patients but had no effect on L. tropica cases.ConclusionsThe response of CL patients to a national treatment protocol appears to depend on several factors, including Leishmania parasite species, geographical location and occurrences of SI. Our findings suggest there is a need to implement alternative CL treatment protocols based on these parameters.

Highlights

In the Kingdom of Saudi Arabia (KSA), Leishmania major and L. tropica are the main causative agents of Old World cutaneous leishmaniasis (CL)
L. tropica was detected in a few cases from the Al Madinah region, with one particular village reporting the presence of both L
The findings of this study demonstrate that patient responses to current anti-leishmanial treatment vary between the different CL endemic areas and are partially dependent on the development of secondary infections (SI)

Summary

Introduction

In the Kingdom of Saudi Arabia (KSA), Leishmania major and L. tropica are the main causative agents of Old World cutaneous leishmaniasis (CL). Al‐Salem et al Parasites Vectors (2019) 12:195 involving vector and reservoir control Due to this well-designed national control programme, the number of formally registered CL cases in KSA has dropped since 1987, from ~17,000 to ~2000 cases per year in 2015 [14]. Around 35% of the country’s work force consists of visitors arriving from other leishmaniasisendemic countries Both anthroponotic (caused by L. tropica) [10, 17, 22] and zoonotic (caused by L. major) [6, 15, 23, 24] CL have been reported in KSA, but very little is currently known about the national distribution of these parasite species

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