Leishman-Donovan Research Articles

Evaluation of CD1a immunostaining in the diagnosis of cutaneous leishmaniasis caused by Leishmania donovani in Sri Lanka

Abstract Cutaneous leishmaniasis (CL) is a vector-borne parasitic disease, routinely diagnosed by direct light microscopy. The sensitivity of this method is dependent on the number of parasites present in the lesion. Immunoexpression of CD1a surface antigen by Leishmania amastigotes and its application as a diagnostic tool has been recently demonstrated in several species including Leishmania major, Leishmania tropica and Leishmania infantum. Leishmania donovani is the only reported species in Sri Lanka primarily causing CL and its CD1a status remains unexplored. We studied CD1a expression by amastigotes of L. donovani in skin biopsies from 116 patients with suspected CL. The biopsy sections were stained with CD1a clones O10 and MTB1 separately. Slit skin smear (SSS) results were considered the gold standard for diagnosis of CL. 103 cases were confirmed through SSS where 73 of them showed positive parasite staining for CD1a clone MTB1 with 70.9% sensitivity. Positivity was seen mostly in parasites closer to the epidermis. CD1a clone O10 failed to detect any amastigotes. Test sensitivity improved to 74.1% when the analysis was applied only to patients with low/no discernible Leishman-Donovan (LD) bodies in histology. Our findings show that CD1a clone MTB1 successfully stains amastigotes of L. donovani species and can be used as a supplementary diagnostic tool in detecting CL, especially when LD bodies are low in number. This method could be validated to detect other forms of leishmaniasis caused by L. donovani in Indian and sub-Saharan regions.

Cytomorphological Variations of Leishman-Donovan Bodies Found in Cutaneous Leishmaniasis Patients in Sri Lanka

Abstract Leishmania parasites undergo a dimorphic life cycle. Diagnosis of cutaneous leishmaniasis (CL) is primarily made by the microscopic identification of the amastigote form of the parasite in a smear. Therefore, correct identification of Leishman-Donovan (LD) bodies in smears is crucial for CL confirmation. The aim of this study was to provide a broad overview of different cytomorphologies of LD bodies to improve the sensitivity of microscopic detection of Leishmania donovani, which causes CL in Sri Lanka. A total of 125 smears, prepared from patients who met the positive diagnostic criteria of CL, were Giemsa stained and examined microscopically. The density, cellular location and all possible cytomorphological forms of the parasite were documented. A total of 10 different cytomorphological forms of LD bodies were identified. Among them, the round form was observed only intracellularly. The other morphological forms, namely the pear shape, cigarette shape, candle flame form, embryo shape, flagellate form, binary form and rosette form, were found only extracellularly. The spindle form and lens shape were observed in both intracellular and extracellular locations. L. donovani amastigotes have a wide range of morphologies besides their classical forms. Although Leishmania are considered as obligatory intracellular parasites, they manage to survive successfully within the extracellular hostile conditions as well. Therefore, having a broader view of different morphological forms for Leishmania parasites may help to improve diagnosis of CL.

PCR Based Detection of Cutaneous Leishmaniasis

Background: The second most common illness after malaria that is transmitted by vectors and that may be lethal if untreated is leishmaniasis. Leishmaniasis is caused by parasites of the genus Leishmania, which are classified into two subgenera, Viannia and Leishmania. Methodology: A total of 100 sample collected from presumed clinically as CL patients by dermatologist, with 50 positive cases and 50 negative cases on Geimsa stain microscopy for Leishman Donovan (LD) bodies. After permission from Ethical board in Khyber medical university KPK and inform consent from patient or their guardian in case of children was taken. The lesion and its surroundings were cleaned with 70% ethanol, and the fluid oozing out of the first prick was obtained and disperse over a glass slide, left to dry and fixed with methanol, and stained with Giemsa stain. Two pricks were administered with a sterile BD syringe at the active margin of the lesion. The second prick's fluid was collected and kept in an EDTA tube for PCR usage at -20°C at the IBMS laboratory of KMU in Peshawar. Results: Out of 100 CL patients, 53 were female and 47 were male. The patients age was ranged from two year to 89 year. PCR was positive in 64 cases and negative in 36 cases out 100 for CL. Out of 50 positive microscopic cases 37cases were positive on PCR. Out of 50 microscopic negative cases 27 (54%) were positive by PCR. A statistically significant difference was found between PCR and microscopic method in the detection of CL. Conclusion: The finding in our study specifies that PCR base analysis is superior to microscopy for diagnosis of CL. Therefore, we recommend use of PCR for the detection of CL along with Giemsa staining in order to improve the quality and sensitivity of routine diagnosis of the disease. Keywords: Polymerase Chain Reaction, Giemsa staining, Cutaneous leishmaniasis

Oceanimonas sp. BPMS22-derived protein protease inhibitor induces anti-leishmanial immune responses through macrophage M2 to M1 repolarization

The present study aimed to validate the potential of a novel serine protein protease inhibitor (PPI), purified from marine Oceanimonas sp. BPMS22, induced M2 to M1 repolarization of the macrophages to treat visceral leishmaniasis (VL). Peptide mass fingerprint of the purified trypsin digested PPI peptide was obtained using matrix-assisted laser desorption ionization-time of flight combined with tandem mass spectrometry (MALDI-TOF MS/MS) and the sequence was used to construct a 3D protein model by homology modelling. The IC50 of PPI were 25.28 ± 1.675 μg/mL and 0.415 ± 0.015 μg/mL against promastigotes and intracellular amastigotes, respectively, indicating the host-directed therapy using PPI. The PPI enhanced the effector molecule i.e., nitric oxide (NO), and dampened the arginase activity in a dose-dependent manner. In vitro studies revealed that the BPMS22-derived PPI significantly (p < 0.05) decreased the mRNA expressions of M2 markers (FIZZ-1, YM-1, CD206, Arg-1) and increased the mRNA expressions of M1 markers (iNOS, IL-1β, IL-12) in rIL-4 + rIL-10 induced M2 macrophages. Interestingly, the BPMS22-derived PPI also significantly (p < 0.05) decreased the FIZZ-1, YM-1, CD206, and Arg-1; significantly (p < 0.05) increased iNOS, IL-12, and IFN-γ mRNA expression in L. donovani -infected murine macrophages, alongside the decreased parasite load in it. Hence, PPI has the potential to repolarize the cytokines (rIL-4 + rIL-10) pre-stimulated and L. donovani-infected M2 macrophages to M1 phenotype in vitro. A decrease in parasite burden after treatment with PPI indicated the acceleration of the parasite killing by enhancing the macrophage effector functions. Further, in vivo PPI treatment reduced hepatic and splenic Leishman donovan units (LDU) up to 93.34 % and 87.63 %, respectively. This was followed by a surge in pro-inflammatory cytokines and dampening anti-inflammatory cytokines (p < 0.01), which exhibited anti-VL immunity. These observations might open new perspectives on PPI in macrophage repolarization to treat VL.

Cytodiagnosis of Visceral Leishmaniasis in Lymph Node Aspirate: A Rare Case Report

Leishmaniasis is a parasitic disease caused by leishmania species. There are three main forms of the disease: Cutaneous, Mucocutaneous and Visceral Leishmaniasis (VL). VL with lymphadenitis is an uncommon presentation. Visceral leishmaniasis is usually diagnosed by identification of parasite Leishman Donovan (LD) bodies in bone marrow aspirates but cytological diagnosis of VL on lymph node aspirates has rarely been reported. This is a case report of a 37-year-old male presenting with multiple isolated cervical lymphadenopathy for three months. The lymphadenopathy was initially suspected to be tubercular in nature which is highly prevalent in India and lymphadenopathy is its common presenting feature, but on Fine Needle Aspiration Cytology (FNAC) of the node, multiple leishmania parasites were identified. Lymphadenopathy due to leishmaniasis is rare in India and most of the previous cases reported have association of leishmaniasis with Human Immunodeficiency Virus (HIV) infection. But this case is unusual as it is not associated with HIV infection. Thus, leishmaniasis should be included in the differential diagnosis of lymphadenopathy, especially in patients coming from endemic region. Cytology can be very helpful in such cases for early diagnosis and further management.

Pediatric Cutaneous Leishmaniasis: A Clinico-Epidemiological Study from North India.

Background:There has been an upsurge in the cases of cutaneous leishmaniasis over the past few years in the pediatric population of Jammu and Kashmir, hitherto a nonendemic area for the disease., The aim of this study was to describe the clinico-epidemiological profile and therapeutic outcome of pediatric cutaneous leishmaniasis (PCL) over a 10-year period in J and K.Materials and Methods:An observational study was conducted at two tertiary care hospitals of Jammu and Kashmir over a period of 10 years (July 2010–June 20). Children presenting to the outpatient department with lesions suggestive of CL were enrolled. Patients suspected of having CL based on clinical criteria were subjected to slit skin smears (SSS) and histopathological examination (HPE) for validation of the diagnosis. Intralesional or systemic sodium stibogluconate (SSG) was the treatment modality used for the management of patients. Clinical follow-up was done at intervals of 2 weeks for the first 2 months and monthly thereafter.Results:A total of 376 cases of CL in children aged 1.5–15 years (mean age 8.4 ± 1.4 years) were included in the study. The duration of the disease ranged from 8 to 52 weeks (mean 22.52 ± 1.5 weeks). Lesions were noted mainly on exposed parts of the body, with face being the most commonly affected site (89.0%). Nodulo-ulcerative plaques were the predominant clinical presentation (62.76%). The diagnosis was confirmed by the demonstration of Leishman Donovan (LD) bodies in 54.25% on SSS- and 25.79% on hematoxylin and eosin -stained tissue sections. In cases where diagnosis could not be confirmed by demonstration of LD body, a histological pattern conforming to CL and response to a therapeutic trial of SSG provided evidence of leishmanial infection. Complete healing was achieved in 95.02% of the cases at the end of treatment.Conclusion:CL is an emerging health problem in the pediatric population of Jammu and Kashmir. Awareness among pediatric health workers regarding this disease and recognition among the differential diagnosis of ulcerated papules or plaques in the pediatric population is imperative.

Spectrum of clinicohematological profile and its correlation with average parasite density in visceral leishmaniasis.

Background:Leishmaniasis is the prevalent in tropical and subtropical regions of the world. Demonstration of Leishman-Donovan (LD) bodies in the bone marrow aspirates (BMA) is vital to diagnosis of visceral leishmaniasis (VL). In the present study, we studied the clinicohematological parameters encountered in VL and correlated them with parasite load on BMA.Methods:Retrospective analysis over 3 years was done; clinical details, biochemical profile, complete hemogram with peripheral smear findings, and BMA smears were reviewed and average parasite density (APD) calculated in each case. Multivariate analysis and tests of significance were applied.Results:The study included 28 patients. Splenomegaly showed a positive trend with APD. rK39 antigen detection test was 100% positive in select cases. A strong negative correlation was observed between albumin to globulin ratio and grade of APD. BMA revealed hemophagocytosis (HPS) in 78.57% cases and it had a significant strong correlation with APD (P = 0.014). A significant correlation was also observed between APD and bone marrow plasma cell percentage (P = 0.01). LD bodies were noted in unusual locations such as within myelocytes (14.2%), plasma cells (7.1%), and megakaryocytes (10.7%).Conclusion:HPS and bone marrow plasmacytosis were two statistically significant findings, which showed positive correlation with parasite load. The presence of these two findings should prompt hematopathologists for more focused search of hemoparasites in BMA to arrive at a definitive diagnosis. This will avoid unnecessary workups and improve the prognosis. To the best of our knowledge, a statistical correlation between APD and clinicohematological parameters has never been previously studied.

Cutaneous leishmaniasis in children: A case series

Background: Cutaneous leishmaniasis (CL) is a protozoal disease usually caused by Leishmania major and Leishmania tropica and transmitted by the bite of a sandfly. It is usually characterized by a single, polymorphous lesion located in an uncovered area. Aims: This study aimed to evaluate the clinico-epidemiological characteristics of CL among children. Materials and Methods: It was a retro-prospective study carried out over a period of 18 months in our center, in which the clinico-epidemiological features of children presenting with CL were assessed. Results: A total of 10 children (male:female - 7:3) were included in the study with the age range of 1–15 years, with a mean age of 8.8 years. Face was the most commonly affected site (n = 8), followed by neck and hands (1 each), and nodulo-ulcerative was the most common clinical type seen in nine patients. Skin smears for Leishman–Donovan (LD) bodies were positive in five patients while the skin biopsy, which was done in four cases, showed the presence of LD bodies in only one patient. Conclusion: CL is a common presentation among children, especially in the endemic areas, and the clinical features are similar to the adult onset disease.

The Role of Histopathology and Immunohistochemistry in the Diagnosis of Cutaneous Leishmaniasis Without "Discernible" Leishman-Donovan Bodies.

Histopathology plays an important role in the diagnosis of cutaneous leishmaniasis (CL) but Leishman-Donovan (LD) bodies may not always be discernible. Recently, anti-CD1a antibody (Ab), clone MTB1, was found to decorate LD bodies immunohistochemically. Can histopathology without discernible LD bodies be used to diagnose CL, and can immunohistochemistry using anti-CD1a Ab, clone MTB1, detect LD bodies in these cases. Suspected CL lesions were studied histopathologically and immunohistochemically, and the patients' clinical files were reviewed. Of the 196 patients with suspected CL, direct smear demonstrated LD bodies in 50 (25.5%). Of the remaining 146 patients, 118 underwent biopsy. In 56 (47.5%) patients, the hematoxylin-eosin-stained sections revealed LD bodies. In 47 (39.8%) patients, LD bodies were not discerned but the histopathology demonstrated histiocytic infiltrates with varying numbers of plasma cells along with other inflammatory cells, and negative Ziehl-Neelsen and periodic acid-Schiff stains. This pattern was termed "histopathology consistent with leishmaniasis." The history, clinical findings, and response to anti-leishmania therapy supported the diagnosis of CL in all of them, and immunostains for CD1a, clone MTB1, detected LD bodies in 11 (23.4%) of these 47 patients. "Histopathology consistent with CL" along with appropriate clinical findings supports the diagnosis of CL in an endemic area, and immunostains with CD1a Ab, clone MTB1, may help in the minority of the cases.

Recurrence of visceral and muco-cutaneous leishmaniasis in a patient under immunosuppressive therapy

BackgroundLeishmaniasis is a protozoan disease caused by parasites of the genus Leishmania, transmitted to humans by sandflies. The diagnosis of leishmaniasis is often challenging as it mimics many other infectious or malignant diseases. The disease can present in three ways: cutaneous, mucocutaneous, or visceral leishmaniasis, which rarely occur together or consecutively.Case presentationThe patient was a 52 years old immunosuppressed Belgian woman with a long history of severe rheumatoid arthritis. She underwent bone marrow biopsy to explore thrombocytopenia. Diagnosis of visceral leishmaniasis was made by identification of Leishman Donovan (LD) bodies in macrophages. Treatment with liposomal amphotericin B was successful. She later developed cutaneous leishmaniasis treated with amphotericin B lipid complex. She next presented with relapsing cutaneous lesions followed by rapidly progressing lymphadenopathies. Biopsy confirmed the diagnosis of leishmaniasis. Treatments by miltefosine, amphotericin B, N-methyl-glucamine antimoniate were subsequently initiated. She later presented a recurrent bone marrow involvement treated with intramuscular paromomycin and miltefosine. She died two years later from leukemia. At the time of death, she presented with a mucosal destruction of the nose. A Leishmania-specific PCR (Polymerase Chain Reaction) identified L. infantum as etiological agent.ConclusionsClinicians should be aware of the potential concomitant or sequential involvement of multiple anatomic localizations of Leishmania in immunosuppressed patients.

Evaluation of a rapid diagnostic test method in kala-azar &amp; Pkdl cases in a tertiary care centre of Eastern India

Background & objectives: Definitive diagnosis of kala-azar requires demonstration of parasites in tissue or bone marrow. In the present study, the diagnostic utility of rK-39 immunochromatographic test (ICT) strip for the diagnosis of kala-azar and post kala-azar dermal leishmaniasis (PKDL) at a tertiary care centre of Eastern India was done. Methods: The study was conducted from January 2011 to December 2011 on 100 suspected kala-azar and PKDL cases. Results: Of the 100 samples, 36 were positive by ICT; of which, 32 were diagnosed as kala-azar (25 males mainly in children of age group 0-20 yrs -(7)) and 4 as PKDL (all 4 males) The rest 64 controls included individuals with malignancies, haemolytic disorders, chronic liver diseases, etc. All had fever of duration ranging from <1 month to 1.5 yr (median 4.5 months). All PKDL patients gave past history of kala-azar and their slit skin test smears were microscopically positive for Leishman-Donovan (LD) bodies. The strip test was positive in all the cases of kala-azar and PKDL (sensitivity 100%) and negative in all control sera (specificity 100%).

Panniculitis is a common unrecognized histopathological feature of cutaneous leishmaniasis.

Cutaneous leishmaniasis (CL) is a parasitic cutaneous infection caused by Leishmania parasite. The histopathology is usually granulomatous in nature. The aim of the present study is to elucidate the histology of CL and evaluate the presence and the frequency of panniculitis among the affected patients. Case series interventional study. Thirty-five patients with CL were diagnosed clinically between December-2012 and May-2013. Diagnostic confirmation established by smears, culture, and polymerase chain reaction (PCR). The histopathological assessment was carried out to study the general pathology and to look for the presence of panniculitis. Simple statistics utilized via SPSS version 16.0 (SPSS, Inc., Chicago, USA). Eighteen women and 17 men with CL were enrolled in the present work with a mean duration of their disease was 3 months. The results of the diagnostic tests were as follow: The smear was positive in 21 (60%) of cases, Leishman-Donovan (LD) bodies were seen in 7 (20%) patients, culture was positive in 24 (68%), and PCR was positive in 32 (91.4%) patients. The epidermal changes included acanthosis, pseudoepitheliomatous hyperplasia, ulceration, focal spongiosis, and interface dermatitis while the dermal changes were dependent on the spectrum of the disease, so in the ulcerative lesions there was lymphohistiocytic infiltration with foci of plasma cells and sometimes aggregate of LD bodies, whereas in the dry lesions the pathology is mainly of epithelioid granuloma. Panniculitis was seen in 16 (46%) cases as a diffuse lymphohistiocytic infiltration of both the septum and lobules of the subcutaneous layer of the skin. Panniculitis is an important feature of CL that must be differentiated from other diseases that can simulate CL such as chronic skin infections, Discoid lupus erythematosus, and cutaneous lymphoma.

Role of Haematological Changes in Predicting Occurrence of Leishmaniasis- A Study in Kumaon Region of Uttarakhand.

A number of cases of Leishmaniasis have been reported from non-endemic sub-himalayan regions of India. Due to low clinical suspicion and atypical presentation, cases may go undetected or there may be a delay in diagnosis. The aim of the study was to evaluate clinico-haematological parameters and bone marrow findings so that a high degree of suspicion could be made in unsuspected cases of Visceral Leishmaniasis (VL) and Leishman Donovan (LD) body negative bone marrow smears. A retrospective study was conducted at a tertiary care centre serving the kumaon region of Uttarakhand from 2010 to 2014. Forty bone marrow aspirates were included, which were sent on clinical suspicion of VL. Twenty cases were positive for LD bodies. Their clinico-haematological features including bone marrow findings were studied in detail and compared with rest of the 20 LD negative cases. Five LD negative cases were also positive for rk39. Twenty LD positive cases were evaluated. Splenomegaly was the most common sign present in 17 cases (85%). Anaemia, leucopenia and lymphocytosis were present in all the cases (100%). Pancytopenia was seen in 17 cases (85%). Microcytic hypochromic blood picture was the most common finding in 11 cases (55%). Bone marrow was normocellular in 7 cases (35%), hypercellular in 7 cases (35%). Erythropoesis was micro-normoblastic in 11 cases (55%). Overall, there were 25 cases of VL (20 LD positive, 5 LD negative). Increased plasma cells, lymphocytes and histiocytes were seen in 17 cases (68%) of VL. In non-endemic region where clinical suspicion is low, bone marrow findings can be a strong indicator for VL even though marrow is negative for LD bodies. If required other ancillary investigations can also be ordered. This study also emphasizes the need for epidemiological work up in this region.

Histopathological characteristics of post kala-azar dermal leishmaniasis: a series of 88 patients.

Post kala azar dermal leishmaniasis (PKDL) is a sequel to visceral leishmaniasis or kala azar seen predominantly in the Indian subcontinent and Africa. Histopathological descriptions of the condition are limited. Biopsies of 88 skin and 16 mucosal lesions were evaluated for histopathological findings on formalin-fixed, paraffin-embedded tissues. There were 71 (80.7%) males and 17 (19.3%) females with a mean age of 24.8 and 28.5 years, respectively. A past history of kala azar was present in 64 (72.7%) patients and post kala azar dermal leishmaniasis developed a mean of 6.2 years after visceral leishmaniasis. Of the biopsies studied, the clinical lesions were macular in 14 (15.9%), papulo-nodular in 32 (36.3%) and showed both macules and papulo-nodules in 42 (47.8%). Follicular plugging was a common epidermal finding. A clear Grenz zone was frequently noted. The dermal infiltrates were arranged mainly in three patterns: superficial perivascular infiltrates in 16 (18.1%), perivascular and perifollicular infiltrates in 24 (27.3%) and diffuse infiltrates in 41 (46.6%) biopsies. Leishman-Donovan (LD) bodies were noted in 13 (44.9%) of 69 cases on slit-skin smear and in 25 (28.4%) of 88 biopsies. In 16 patients, where both skin and mucosal biopsies were available, LD bodies were identified in 10 (62.5%) mucosal biopsies as compared to 3 (18.7%) skin biopsies. The retrospective nature of the study and the lack of controls were limitations. The various histomorphological patterns of post kala azar dermal leishmaniasis are a useful clue to the diagnosis even when LD bodies have not been detected. This study also suggests that LD bodies are more frequently seen in mucosal biopsies in comparison to cutaneous biopsies.

Post-kala-Azar dermal leishmaniasis: A diagnostic dilemma in a nonendemic area.

Post-kala-Azar dermal leishmaniasis: A diagnostic dilemma in a nonendemic area.

Leishman-Donovan (LD) bodies in bone marrow biopsy of an adult male with AIDS.

doi:10.5152/tjh.2010.36 We report the case of Leishman-Donovan (LD) bodies in the bone marrow biopsy of an Iraqi adult male with acquired immunodeficiency syndrome (AIDS). The patient was working in a United States military camp in Baghdad, Iraq. He was diagnosed as having human immunodeficiency virus (HIV) infection within only a few days of diagnosis of visceral leishmaniasis (kala-azar). Visceral leishmaniasis is one of the opportunistic infections in AIDS patients. The interesting point of this case is that the finding of LD bodies in the bone marrow biopsy is rare. In this case, the bone marrow aspirate was diluted, and this caused us to miss the diagnosis of visceral leishmaniasis. However, when we examined the biopsy slides, the diagnosis was clear. A

Post-kala-azar dermal leishmaniasis in HIV-positive patients: A study of two cases

Cutaneous leishmaniasis and human immunodeficiency virus (HIV) co-infection is emerging as increasingly frequent and serious new disease. Leishmaniasis may be acquired before or after HIV infection. We describe two cases of post-kala-azar dermal leishmaniasis in HIV-positive patients. Both the patients had papulonodular lesions on upper extremities and back with low CD4 count. Slit skin smear with giemsa stain revealed Leishman Donovan (LD) bodies and skin biopsy of both the patients revealed lymphohistiocytic infiltrate with numerous intracytoplasmic LD bodies.

Morphological findings in bone marrow biopsy and aspirate smears of visceral kala azar: A review

Visceral leishmaniasis (VL) is endemic in India and may simulate and cause many hematological disorders like pancytopenia, myelofibrosis, myelodysplasia and hemophagocytosis. The study aims to investigate the hematological manifestation of Visceral Leishmaniasis and associated changes that may be observed in bone marrow aspirate smears and biopsy which may warn a pathologist of possible infections. This is a retrospective study of 18 VL cases on B (b) one marrow aspirate and biopsy in the department of Pathology in a tertiary care teaching hospital in New Delhi. Giemsa stained slides of bone marrow aspirates and hematoxylin and Eosin stained biopsy slides were reviewed in detail by two competent pathologists. All the findings were tabulated and discussed and comparisons made with the previous similar studies. Hyper cellular marrow, increased lymphocytes and plasma cells, marrow granulomas, hemophagocytosis, myelofibrosis, myelodysplasia and gelatinous transformation of the marrow were notable features the presence of which together or individually should caution a pathologist to search for Leishman Donovan (LD) bodies in patients especially in a non-endemic zone in a tropical country.

Searching for cutaneous leishmaniasis in tribals from Kerala, India

Background:In India, indigenous cases of cutaneous leishmaniasis (CL) are mainly confined to the northwestern region. But now, more and more case reports are coming in from other parts of India. In January 2009, a 26-year-old lady residing in a forest area in Thiruvananthapuram district of Kerala State presented with bluish red nodules on her upper extremities, of six months duration, which was clinically more in favor of cutaneous leishmaniasis. She had never gone out of the district of Thiruvananthapuram in her life.Aim:To investigate whether the patient hails from a new endemic focus of cutaneous leishmaniasis.Setting and Design:An epidemiological investigation in the form of a survey was carried out in March 2009 by a multidisciplinary team among 63 persons residing in the Mele Aamala and Aayiramkala forest tribal settlements in Kuttichal Panchayat of Thiruvananthapuram district.Material and Methods:History taking and clinical examination of 38 persons in the area with special consideration to skin lesions was undertaken. Microbiological and histopathological examination of the skin lesions was done. Breeding places of sand fly and possible reservoirs of Leishmania were also simultaneously investigated.Statistical analysis used:The data obtained was tabulated as frequency and percentage. Chi-square test was done to find out the statistical significance of differences in distributions.Results:Out of the 38 persons examined, active lesions were found in 12 persons and six had healed lesions. Tissue samples were obtained from seven out of the 12 suspected cases. Four of them showed Leishman Donovan (LD) bodies in tissue smears. Out of the cultures taken from three patients, one showed promastigote forms in Novy McNeal Nicolle (NNN) medium. Histopathological study was done in five patients and two patients had LD bodies, one had epithelioid cell granuloma and the other two had mixed infiltrate with predominantly macrophages. All the three investigations were carried out in three patients and out of them one showed positivity in all the three investigations and the rest two were positive in tissue smear and histopathological examination. Sandflies collected from the area gave an indirect evidence of its role in the disease transmission in the area.Conclusion:The clinical, microbiological and histopathological evaluation of the skin lesions was consistent with cutaneous leishmaniasis. But none of the patients gave history of travel outside the district before the onset of the disease and no one had newly moved into this area within the last two years. So this may be considered as probably a new focus of cutaneous leishmaniasis

New Cytologic Clues in Localized Leishmania Lymphadenitis

To describe new cytologic clues to diagnose localized leishmania lymphadenitis (LLL).The study examined cytologic smears of 170 cases of LLL referred to our department from November 1989 to October 2004. A total of 120 cases were confirmed by detecting Leishman-Donovan (LD) bodies in at least 1 of the cytologic smears and 50 cases, which were histologically confirmed. For comparison we studied cytologic smears of 20 cases of tuberculous lymphadenitis, 20 cases of toxoplasma lymphadenitis and 20 cases of granulomatous lymphadenitis of unspecified causes.Cases were divided into 4 major groups. Cytologic findings in these groups were studied to find highly suggestive clues. Cytologic findings present in most of these groups, but absent or very rare in other granulomatous lymphadenitis, were LD kinetoplasts, plasma cells with different shapes of inclusions and lymphogranular bodies. Rare findings not reported previously were: intraneutrophilic LD bodies, hematoxylin body-like inclusions, fibroblasts, cytoplasmic blebbing and floating parasitophorous vacuoles.Despite previous reports emphasizing detecting LD bodies in diagnosing LLL, we present cytologic clues highly suggestive of this self-limited disease when LD bodies cannot be detected or are very few on the smears.