Academic journal article Bulletin of the World Health Organization

Current Status of Cutaneous Leishmaniasis in Aleppo, Syrian Arab Republic

Academic journal article Bulletin of the World Health Organization

Current Status of Cutaneous Leishmaniasis in Aleppo, Syrian Arab Republic

Article excerpt

Introduction

Cutaneous leishmaniasis has been endemic in Aleppo, Syrian Arab Republic for generations; its occurence was documented as early as 1745 by Pocock (1). Common local names include "Aleppo boil" and "the one-year sore". The infective agent is Leishmania tropica (2). Oriental cutaneous leishmaniasis caused by Leishmania tropica is known to heal spontaneously within 1-2 years in about 90% of cases, with scar formation and subsequent life-long immunity against the disease in most cases (3).

In the mid-1950s, and after a campaign aimed at controlling malaria (1), cutaneous leishmaniasis declined considerably; however, before the end of the 1960s, it had regained momentum.

In the early 1970s, treatment with pentavalent antimonials was introduced, with meglumine antimoniate being used exclusively until sodium stibogluconate was introduced in the early 1980s. Substantial success in shortening the course of the disease and in reducing scarring to a minimum was achieved using these compounds. Intralesional administration of meglumine antimoniate alone was (and remains) the treatment of choice for cutaneous leishmaniasis in Aleppo; 3-5 intralesional doses at weekly intervals used to be sufficient for the complete healing of lesions(4, 5). Occasionally, antimonials were given systemically when their intralesional use was not possible owing to the location, size or number of lesions. A few cases of acute cutaneous leishmaniasis did develop into the chronic or lupoid forms despite treatment, but these did not exceed 3-5% of the total(5, 6).

Since 1992, there has been a clear but unexplained increase in the overall incidence of cutaneous leishmaniasis in Aleppo, despite repeated governmental insecticide spraying campaigns to combat the sandfly vector. This change was reported in 1993 (7), and has been noted subsequently in Ministry of Health reports. Moreover, patients began to require more intralesional doses of meglumine antimoniate before they responded. Gradually, however, even with the additional doses, the treatment became ineffective in a considerable proportion of cases, and more and more patients developed the chronic form of the disease.(a) Such patients were transferred from one clinic to another and were subjected to various. treatments repeatedly without recovery (see Table 2). This increasing lack of response suggested that the parasite might be showing resistance to the antimonial compounds used in treatment.

Table 2: Details of previous treatments received by the 64 study patients with chronic cutaneous leishmaniasis

No. of patients   Type of treatment(a)   No. of sessions, treatment

18                Intralesional
                   alone                 3-50, intralesional

 4                Systemic alone         10-20, systemic

22                Intralesional
                   them                 2-68, intralesional
                   systematic           2-20, systemic

 8                Intralesional then
                   cryocautery(b)       1-50, intralesional
                                        2-10, cryocautery

 3                Intralesional then
                   intralesional        25-30, intralesional
                   steroids             1-2, intralesional steroids

 2                Intralesional then
                   systemic
                   then                 16-25, intralesional
                   cauterization        10, systemic before
                                         cauterization

 2                 Intralesional
                    then                10, intralesional
                    cryocautery then     5, cryocautery
                    intralesional        3, intralesional steroids
                    steroids

 5                 Intralesional then
                    systemic            15-20, intralesional
                    then cryocautery    1-14, systemic
                    then                1-2, cryocautery
                    intralesional       1-2, intralesional steroids
                    steroids

(a) Unless otherwise indicated, intralesional and systemic treatment was with pentavalent antimonials. …

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