BJD
Research letter
Clinical features of Old World cutaneous leishmaniasis in elderly patients
British Journal of Dermatology
Table 1 Separated frequency distribution of the clinical forms of leishmaniasis in the two age groups Patients, n (%)
DOI: 10.1111/bjd.13431 DEAR EDITOR, Leishmaniasis encompasses a group of chronic infections caused by over 20 species of the Leishmania genus. It is transmitted by sandflies between animal and human hosts and accounts for a complicated health problem in endemic areas, often of developing countries.1 The elderly population has specific health characteristics: alterations in the immune system,2 hormonal changes,3 altered attention to illness and treatment, irregular and multiple drug consumption, comorbidities and different disease presentations.4,5 M€ uller et al.2 have shown that in older rats the severity of leishmaniasis lesions and the number of parasites were less than in younger rats. Davies et al.6 have reviewed the epidemiology of leishmaniasis in five countries in South America; they reported a lower number of lesions in older people. However, Guessous-Idrissi et al.7 indicated more severe and larger lesions in older patients in an epidemiological study in north Morocco. A shortage of studies about leishmaniasis in the elderly population and their contradictory results encouraged us to conduct a descriptive prospective study between April 2010 and March 2011 on confirmed cases of cutaneous leishmaniasis in Mashhad, Iran, to evaluate the clinical features of cutaneous leishmaniasis in two age groups: a younger group (age ≤ 20 years) and an older group (age ≥ 60 years). Demographic data, the past medical history of the patients, and the site, number, size and duration of the lesions were recorded. The clinical manifestation and the pattern of lesions were categorized as stated in Table 1. The area of lesions was calculated as a circle, the diameter of which was the mean of the largest and smallest diameter of each lesion. We studied 598 cases of cutaneous leishmaniasis (284 male and 314 female) aged under 20 years (age range 02–20 years, mean SD = 97 59 years) and 152 cases (55 male and 97 female) over 60 years old (age range 60–96 years, mean SD = 667 84 years). The head and neck was the most common site of involvement in younger patients (671% of lesions), while in the older patients the upper extremities encompassed the most lesions (638% of lesions). In the lower extremities and trunk there were no significant differences between the two age groups. The average number of lesions and the mean size of lesions were larger in the over-60s group (238 221 vs. 532
British Journal of Dermatology (2015) 172, pp532–533
Type of lesion
Age ≤ 20 years
Age ≥ 60 years
P-value
Papule Plaque Nodule Ulcerated papule Ulcerated plaque Ulcerated nodule Lupoid Erysipeloid Hyperkeratotic Sporotrichoid Eczema form Tumoral Paronychia
184 214 100 14 76 21 51 0 3 0 2 4 3
21 51 36 6 44 8 6 8 0 3 1 1 1
0001 0607 0047 0265a 0001 0317 0057 0001a
(308) (358) (167) (23) (127) (35) (85) (05) (03) (07) (05)
(138) (336) (237) (39) (289) (53) (39) (53) (2) (07) (07) (07)
a Fisher’s exact test. Papule: slightly elevated solid lesion ≤ 05 cm in the largest diameter; Plaque: slightly elevated solid lesion > 05 cm in the largest diameter; Nodule: plaque with a significant height and or deep infiltration of 05–2 cm; Ulceration: loss of the epidermis; Lupoid: presence of red/brown flattopped papules and plaques without ulceration around an old scar; Erysipeloid: lesions distributed symmetrically on nose and cheeks; Hyperkeratotic: severe keratosis on the surface of a lesion; Sporotrichoid: lymphatic extension with palpable cordlike and/or nodular induration along a lymphatic pathway; Eczema form: acute or subacute exudative inflammation seen on a lesion; Tumoral: a large exophytic or endophytic lesion > 2 cm in largest diameter; Paronychia: an infiltration involving the nail folds.
183 15 lesions, P = 0002; and 94785 1268 vs. 43039 7673 mm2, P < 0001, respectively). Nevertheless, there was no significant difference between the mean interval from the onset of the lesion until seeking treatment in the two age groups (P = 0788). Table 1 shows the clinical features of Old World cutaneous leishmaniasis in the two groups of patients. Among the clinical forms of leishmaniasis, papules, nodules, ulcerated plaques and the erysipeloid and sporotrichoid forms showed significant differences between the two age groups. There were significantly more papules in the younger group, while the other types were more common in the older group. Although in terms of the time between lesion presentation and the initial physician visit there was no significant difference between the two age groups, a significant © 2014 British Association of Dermatologists
Research letter 533 1
correlation was detected between the age and the history of previous treatment (P = 0024). A history of previous treatment was less frequent in the over-60 group (375% vs. 477% of cases). This might be due to the neglect of elderly patients’ wellbeing by relatives, or sometimes even by themselves. It should be noted that in the older age group two cases of renal transplant and three cases of immunosuppression were present, and the lesions were larger in these cases. However, the mean size of lesions in these cases was not statistically different from that in the other patients in that group (146 188 vs. 93 124 cm2; t = 092, P = 035). As confounding variables, the number of lesions in different body sites and the duration of lesions could affect the size of lesions. Controlling these variables with use of a general linear model, the size of lesions in the two age groups showed a statistically significant difference (F = 306, P < 0001). Thus the size and number of lesions were greater in the older patients, which confirms the results of the study of Guessous-Idrissi et al.7 Major changes in the dermis occurring over time, including dispersion and impairment of collagen and elastic fibres,8 and alterations in the cutaneous immune system,9 coupled with other changes, may facilitate the spreading and occurrence of more extensive cutaneous lesions and even erysipeloid forms. In a study of 1250 cases with leishmaniasis in Iran, 17 patients (14%) had erysipeloid forms. Sixteen of these 17 patients with erysipeloid forms were female and aged 50– 75 years.10 This form of facial cutaneous infection in older women may also show the role of hormonal changes in menopausaled women.3 To conclude, despite an approximately equal interval between the two age groups from the beginning of infection to seeking treatment, in the older group the size and number of lesions were greater, and lesions were more frequent on the upper extremities vs. the head and neck area for the younger group.
M.J. YAZDANPANAH1 Cutaneous Leishmaniasis Research Center, 2 Department of Dermatology, Resident of M. BANIHASHEMI1 3 Pathology and Resident of Dermatology, S.M. MOHAMMADI1 School of Medicine, Mashhad University of Z. HATAMI2 Medical Sciences, Mashhad, Iran F. LIVANI3 4 Health Sciences Research Center, Department H. ESMAILI4 of Biostatistics and Epidemiology, School V . M A S H A Y E K H I - G O Y O N L O 1 of Health, Mashhad University of Medical Sciences, Mashhad, Iran Correspondence: Vahid Mashayekhi-Goyonlo. E-mail: [email protected]
Acknowledgments
Funding sources: The research council of the Mashhad University of Medical Sciences, Mashhad, Iran financially supported this study, grant number 6572.
We would like to thank Dr Mohammad Sajadimanesh, Dr Roya Shabahang and Miss Akram Momenzadeh for their cooperation in this research.
© 2014 British Association of Dermatologists
References 1 Nelson SA, Warschaw KE. Protozoa and worms. In: Dermatology (Bolognia JL, Jorizzo JL, Schaffer JV, eds), 3rd edn. Philadelphia, PA: Elsevier Inc., 2012; 1391–421. 2 M€ uller I, Hailu A, Choi BS et al. Age-related alteration of arginase activity impacts on severity of leishmaniasis. PLOS Negl Trop Dis 2008; 2:e235. 3 Salmanpour R, Handjani F, Zerehsaz F et al. Erysipeloid leishmaniasis: an unusual clinical presentation. Eur J Dermatol 1999; 9:458–9. 4 Tan HH, Goh CL. Parasitic skin infections in the elderly: recognition and drug treatment. Drugs Aging 2001; 18:165–76. 5 Gavazzi G, Herrmann F, Krause KH. Aging and infectious diseases in the developing world. Clin Infect Dis 2004; 39:83–91. 6 Davies CR, Llanos-Cuentas EA, Sharp SJ et al. Cutaneous leishmaniasis in the Peruvian Andes: factors associated with variability in clinical symptoms, response to treatment, and parasite isolation rate. Clin Infect Dis 1997; 25:302–10. 7 Guessous-Idrissi N, Chiheb S, Hamdani A et al. Cutaneous leishmaniasis: an emerging focus of Leishmania tropica in north Morocco. Trans R Soc Trop Med Hyg 1997; 91:660–3. 8 Farage MA, Miller KW, Berardesca E, Maibach HI. Clinical implications of aging skin: cutaneous disorders in the elderly. Am J Clin Dermatol 2009; 10:73–86. 9 Sunderk€ otter C, Kalden H, Luger TA. Aging and the skin immune system. Arch Dermatol 1997; 133:1256–62. 10 Momeni AZ, Aminjavaheri M. Clinical picture of cutaneous leishmaniasis in Isfahan, Iran. Int J Dermatol 1994; 33:260–5.
Conflicts of interest: none declared.
British Journal of Dermatology (2015) 172, pp532–533
Research letter
Clinical features of Old World cutaneous leishmaniasis in elderly patients
British Journal of Dermatology
Table 1 Separated frequency distribution of the clinical forms of leishmaniasis in the two age groups Patients, n (%)
DOI: 10.1111/bjd.13431 DEAR EDITOR, Leishmaniasis encompasses a group of chronic infections caused by over 20 species of the Leishmania genus. It is transmitted by sandflies between animal and human hosts and accounts for a complicated health problem in endemic areas, often of developing countries.1 The elderly population has specific health characteristics: alterations in the immune system,2 hormonal changes,3 altered attention to illness and treatment, irregular and multiple drug consumption, comorbidities and different disease presentations.4,5 M€ uller et al.2 have shown that in older rats the severity of leishmaniasis lesions and the number of parasites were less than in younger rats. Davies et al.6 have reviewed the epidemiology of leishmaniasis in five countries in South America; they reported a lower number of lesions in older people. However, Guessous-Idrissi et al.7 indicated more severe and larger lesions in older patients in an epidemiological study in north Morocco. A shortage of studies about leishmaniasis in the elderly population and their contradictory results encouraged us to conduct a descriptive prospective study between April 2010 and March 2011 on confirmed cases of cutaneous leishmaniasis in Mashhad, Iran, to evaluate the clinical features of cutaneous leishmaniasis in two age groups: a younger group (age ≤ 20 years) and an older group (age ≥ 60 years). Demographic data, the past medical history of the patients, and the site, number, size and duration of the lesions were recorded. The clinical manifestation and the pattern of lesions were categorized as stated in Table 1. The area of lesions was calculated as a circle, the diameter of which was the mean of the largest and smallest diameter of each lesion. We studied 598 cases of cutaneous leishmaniasis (284 male and 314 female) aged under 20 years (age range 02–20 years, mean SD = 97 59 years) and 152 cases (55 male and 97 female) over 60 years old (age range 60–96 years, mean SD = 667 84 years). The head and neck was the most common site of involvement in younger patients (671% of lesions), while in the older patients the upper extremities encompassed the most lesions (638% of lesions). In the lower extremities and trunk there were no significant differences between the two age groups. The average number of lesions and the mean size of lesions were larger in the over-60s group (238 221 vs. 532
British Journal of Dermatology (2015) 172, pp532–533
Type of lesion
Age ≤ 20 years
Age ≥ 60 years
P-value
Papule Plaque Nodule Ulcerated papule Ulcerated plaque Ulcerated nodule Lupoid Erysipeloid Hyperkeratotic Sporotrichoid Eczema form Tumoral Paronychia
184 214 100 14 76 21 51 0 3 0 2 4 3
21 51 36 6 44 8 6 8 0 3 1 1 1
0001 0607 0047 0265a 0001 0317 0057 0001a
(308) (358) (167) (23) (127) (35) (85) (05) (03) (07) (05)
(138) (336) (237) (39) (289) (53) (39) (53) (2) (07) (07) (07)
a Fisher’s exact test. Papule: slightly elevated solid lesion ≤ 05 cm in the largest diameter; Plaque: slightly elevated solid lesion > 05 cm in the largest diameter; Nodule: plaque with a significant height and or deep infiltration of 05–2 cm; Ulceration: loss of the epidermis; Lupoid: presence of red/brown flattopped papules and plaques without ulceration around an old scar; Erysipeloid: lesions distributed symmetrically on nose and cheeks; Hyperkeratotic: severe keratosis on the surface of a lesion; Sporotrichoid: lymphatic extension with palpable cordlike and/or nodular induration along a lymphatic pathway; Eczema form: acute or subacute exudative inflammation seen on a lesion; Tumoral: a large exophytic or endophytic lesion > 2 cm in largest diameter; Paronychia: an infiltration involving the nail folds.
183 15 lesions, P = 0002; and 94785 1268 vs. 43039 7673 mm2, P < 0001, respectively). Nevertheless, there was no significant difference between the mean interval from the onset of the lesion until seeking treatment in the two age groups (P = 0788). Table 1 shows the clinical features of Old World cutaneous leishmaniasis in the two groups of patients. Among the clinical forms of leishmaniasis, papules, nodules, ulcerated plaques and the erysipeloid and sporotrichoid forms showed significant differences between the two age groups. There were significantly more papules in the younger group, while the other types were more common in the older group. Although in terms of the time between lesion presentation and the initial physician visit there was no significant difference between the two age groups, a significant © 2014 British Association of Dermatologists
Research letter 533 1
correlation was detected between the age and the history of previous treatment (P = 0024). A history of previous treatment was less frequent in the over-60 group (375% vs. 477% of cases). This might be due to the neglect of elderly patients’ wellbeing by relatives, or sometimes even by themselves. It should be noted that in the older age group two cases of renal transplant and three cases of immunosuppression were present, and the lesions were larger in these cases. However, the mean size of lesions in these cases was not statistically different from that in the other patients in that group (146 188 vs. 93 124 cm2; t = 092, P = 035). As confounding variables, the number of lesions in different body sites and the duration of lesions could affect the size of lesions. Controlling these variables with use of a general linear model, the size of lesions in the two age groups showed a statistically significant difference (F = 306, P < 0001). Thus the size and number of lesions were greater in the older patients, which confirms the results of the study of Guessous-Idrissi et al.7 Major changes in the dermis occurring over time, including dispersion and impairment of collagen and elastic fibres,8 and alterations in the cutaneous immune system,9 coupled with other changes, may facilitate the spreading and occurrence of more extensive cutaneous lesions and even erysipeloid forms. In a study of 1250 cases with leishmaniasis in Iran, 17 patients (14%) had erysipeloid forms. Sixteen of these 17 patients with erysipeloid forms were female and aged 50– 75 years.10 This form of facial cutaneous infection in older women may also show the role of hormonal changes in menopausaled women.3 To conclude, despite an approximately equal interval between the two age groups from the beginning of infection to seeking treatment, in the older group the size and number of lesions were greater, and lesions were more frequent on the upper extremities vs. the head and neck area for the younger group.
M.J. YAZDANPANAH1 Cutaneous Leishmaniasis Research Center, 2 Department of Dermatology, Resident of M. BANIHASHEMI1 3 Pathology and Resident of Dermatology, S.M. MOHAMMADI1 School of Medicine, Mashhad University of Z. HATAMI2 Medical Sciences, Mashhad, Iran F. LIVANI3 4 Health Sciences Research Center, Department H. ESMAILI4 of Biostatistics and Epidemiology, School V . M A S H A Y E K H I - G O Y O N L O 1 of Health, Mashhad University of Medical Sciences, Mashhad, Iran Correspondence: Vahid Mashayekhi-Goyonlo. E-mail: [email protected]
Acknowledgments
Funding sources: The research council of the Mashhad University of Medical Sciences, Mashhad, Iran financially supported this study, grant number 6572.
We would like to thank Dr Mohammad Sajadimanesh, Dr Roya Shabahang and Miss Akram Momenzadeh for their cooperation in this research.
© 2014 British Association of Dermatologists
References 1 Nelson SA, Warschaw KE. Protozoa and worms. In: Dermatology (Bolognia JL, Jorizzo JL, Schaffer JV, eds), 3rd edn. Philadelphia, PA: Elsevier Inc., 2012; 1391–421. 2 M€ uller I, Hailu A, Choi BS et al. Age-related alteration of arginase activity impacts on severity of leishmaniasis. PLOS Negl Trop Dis 2008; 2:e235. 3 Salmanpour R, Handjani F, Zerehsaz F et al. Erysipeloid leishmaniasis: an unusual clinical presentation. Eur J Dermatol 1999; 9:458–9. 4 Tan HH, Goh CL. Parasitic skin infections in the elderly: recognition and drug treatment. Drugs Aging 2001; 18:165–76. 5 Gavazzi G, Herrmann F, Krause KH. Aging and infectious diseases in the developing world. Clin Infect Dis 2004; 39:83–91. 6 Davies CR, Llanos-Cuentas EA, Sharp SJ et al. Cutaneous leishmaniasis in the Peruvian Andes: factors associated with variability in clinical symptoms, response to treatment, and parasite isolation rate. Clin Infect Dis 1997; 25:302–10. 7 Guessous-Idrissi N, Chiheb S, Hamdani A et al. Cutaneous leishmaniasis: an emerging focus of Leishmania tropica in north Morocco. Trans R Soc Trop Med Hyg 1997; 91:660–3. 8 Farage MA, Miller KW, Berardesca E, Maibach HI. Clinical implications of aging skin: cutaneous disorders in the elderly. Am J Clin Dermatol 2009; 10:73–86. 9 Sunderk€ otter C, Kalden H, Luger TA. Aging and the skin immune system. Arch Dermatol 1997; 133:1256–62. 10 Momeni AZ, Aminjavaheri M. Clinical picture of cutaneous leishmaniasis in Isfahan, Iran. Int J Dermatol 1994; 33:260–5.
Conflicts of interest: none declared.
British Journal of Dermatology (2015) 172, pp532–533
