After treatment and apparent recovery from the visceral disease in India and Sudan, some patients develop dermatological manifestations due to local parasitic infection.
In India, dermatological changes occur in a small minority of patients 6 months to at least 3 years after the initial infection. They are seen as macules, papules, nodules (most frequently) and plaques, which have a predilection for the face, especially the area around the chin. The face often appears erythematous. Hypopigmented macules can occur over all parts of the body and are highly variable in extent and location. There are no systemic symptoms and no spontaneous healing.
In Sudan, approximately 50% of patients with VL develop post-kala-azar dermal leishmaniasis (PKDL),experiencing skin manifestations concurrently with VL or within the following 6 months. In addition to the dermatological features described above, a measles-like micropapular rash may be seen all over the body. In Sudan, children are more frequently affected than in India. Spontaneous healing occurs in about three-quarters of cases within 1 year.
The diagnosis is clinical, supported by demonstration of scanty parasites in lesions by slit-skin smear and culture. Immunofluorescence and immunohistochemistry may demonstrate the parasite in skin tissues. In the majority of patients, serological tests (direct agglutination test or k39 strip tests) are positive.
Treatment of PKDL is difficult. In India, Sb for 120 days, several courses of amphotericin B infusions, or miltefosine for 12 weeks is required. In Sudan, Sb for 2 months is considered adequate. In the absence of a physical handicap, most patients are reluctant to complete the treatment. PKDL patients are a human reservoir, and focal outbreaks have been linked to patients with PKDL in areas previously free of VL.
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