Cutaneous Leishmaniasis in Khyber Pakhtunkhwa Province of Pakistan: Clinical Diversity and Species-Level Diagnosis.
This study primarily aimed to identify the causative species of cutaneous leishmaniasis (CL) in the Khyber Pakhtunkhwa Province of Pakistan and to distinguish any species-specific variation in clinical manifestation of CL. Diagnostic performance of different techniques for identifying CL was assessed. Isolates of Leishmania spp. were detected by in vitro culture, polymerase chain reaction (PCR) on DNA extracted from dried filter papers and microscopic examination of direct lesion smears from patients visiting three major primary care hospitals in Peshawar. A total of 125 CL patients were evaluated. Many acquired the disease from Peshawar and the neighboring tribal area of Khyber Agency. Military personnel acquired CL while deployed in north and south Waziristan. Leishmania tropica was identified as the predominant infecting organism in this study (89.2%) followed by Leishmania major (6.8%) and, unexpectedly, Leishmania infantum (4.1%). These were the first reported cases of CL caused by L. infantum in Pakistan. PCR diagnosis targeting kinetoplast DNA was the most sensitive diagnostic method, identifying 86.5% of all samples found positive by any other method. Other methods were as follows: ribosomal DNA PCR (78.4%), internal transcribed spacer 2 region PCR (70.3%), culture (67.1%), and microscopy (60.5%). Clinical examination reported 14 atypical forms of CL. Atypical lesions were not significantly associated with the infecting Leishmania species, nor with "dry" or "wet" appearance of lesions. Findings from this study provide a platform for species typing of CL patients in Pakistan, utilizing a combination of in vitro culture and molecular diagnostics. Moreover, the clinical diversity described herein can benefit clinicians in devising differential diagnosis of the disease.
Department of Zoology, University of Peshawar, Peshawar, Khyber Pakhtunkhwa, Pakistan.|Department of Immunology and Infection, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Nazma Habib
NH
Khan
Combined Military Hospital, Peshawar, Khyber Pakhtunkhwa, Pakistan.
Arfan Ul
AU
Bari
Combined Military Hospital, Peshawar, Khyber Pakhtunkhwa, Pakistan.
Rizwan
R
Hashim
Khyber Teaching Hospital, Peshawar, Khyber Pakhtunkhwa, Pakistan.
Inamullah
I
Khan
Kuwait Teaching Hospital, Peshawar, Khyber Pakhtunkhwa, Pakistan.
Akhtar
A
Muneer
Department of Zoology, University of Peshawar, Peshawar, Khyber Pakhtunkhwa, Pakistan.
Akram
A
Shah
Department of Zoology, University of Peshawar, Peshawar, Khyber Pakhtunkhwa, Pakistan.|Department of Immunology and Infection, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Sobia
S
Wahid
Department of Immunology and Infection, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Vanessa
V
Yardley
Department of Immunology and Infection, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Brighid
B
O'Neil
Department of Immunology and Infection, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Colin J
CJ
Sutherland
D000293:Adolescent; D000328:Adult; D002648:Child; D018105:DNA, Kinetoplast / Q000302:isolation & purification*; D019468:Disease Management; D005260:Female; D006801:Humans; D018314:Leishmania infantum / Q000302:isolation & purification; D018320:Leishmania major / Q000302:isolation & purification; D007895:Leishmania tropica / Q000302:isolation & purification; D016773:Leishmaniasis, Cutaneous / Q000175:diagnosis* / Q000453:epidemiology / Q000469:parasitology*; D008297:Male; D010154:Pakistan / Q000453:epidemiology; D016133:Polymerase Chain Reaction; D013045:Species Specificity; D055815:Young Adult
D018105:DNA, Kinetoplast