Is leishmaniasis adequately notified in Sri Lanka? A survey among doctors from an endemic district, Sri Lanka.

BACKGROUND: Leishmaniasis is a notifiable disease in Sri Lanka since 2008. Previous studies show a gap in the notification of leishmaniasis. The purpose of the present study was to determine the Knowledge, attitudes and practice of medical officers regarding leishmaniasis. METHODS: A cross-sectional study was conducted in the Anuradhapura district which reported the highest case load of leishmaniasis. Medical officers from public and private health care institutes in the area filled a self-administered questionnaire in the presence of the investigators. RESULTS: One hundred and eighty-eight (188) medical officers completed the questionnaire. Of them, 95.7% were aware of leishmaniasis as a parasitic infection and 84.7% correctly identified Leishmania donovani as the causative organism in Sri Lanka. From the respondents, 181 (96.8%) knew that the vector of leishmaniasis is sand fly. Cutaneous leishmaniasis was reported as the most prevalent form of leishmaniasis in the country by 176 (94.1%). Nearly half of the respondents (98, 54.1%) were aware of the fact that the Anuradhapura district has the highest disease burden. Many of them had the idea that leishmaniasis is an emerging disease (155, 84.3%,) and early diagnosis is important in controlling the disease (163, 89.1%). Although about three fourth (123, 73.7%,) of the participants mentioned that leishmaniasis should be notified at first clinical suspicion, only 74 (42.5%) were aware that it is a legal requirement. Some medical officers (39, 22%) believed that the current notification system in the country is not effective. Unavailability of notification forms (60, 36.8%) heavy workload (85, 50.3%) and inadequate supportive staff (55, 35.1%) were reported as barriers for timely notification. Even though 105 (58.0%) of medical officers had suspected leishmaniasis during the last 8 years period only 35 (19.4%) had notified. CONCLUSIONS: Even though more than 90% of the participants had good theoretical knowledge about leishmaniasis; notification of leishmaniasis is considerably inadequate. This study emphasizes the need for greater efforts to improve the notification of leishmaniasis in Sri Lanka.

Randomized, double-blind, comparative study on efficacy and safety of itraconazole pulse therapy and terbinafine pulse therapy on nondermatophyte mold onychomycosis: A study with 90 patients.

BACKGROUND: Nondermatophyte mold (NDM) onychomycosis shows poor response to current topical, oral or device-related antifungal therapies. This study was aimed to determine the efficacy and safety of itraconazole and terbinafine pulse therapy on NDM onychomycosis. METHODS: Mycologically proven subjects were treated with itraconazole 400 mg daily or terbinafine 500 mg daily for 7 days/month; two pulses for fingernails and three pulses for toenails(SLCTR/2013/013). RESULTS: One-hundred seventy-eight patients underwent mycological studies and 148 had positive fungal isolates. NDM were the prevailing fungi, 68.2%, followed by candida species 21.6%, and dermatophytes made up only 10.1%. Out of NDM Aspergillus spp (75.1%) predominated followed by 8.9% Fusarium spp and 4.95% Penicillium spp. The clinical cure at completion of pulse therapy was statistically significant 9.2% versus 2.0% (p < 0.05) in itraconazole group. But no statistically significant difference was detected between the two regimens at the end of 12 months; 65.1% versus 54.64%. Recurrences observed in both groups (6.5% vs. 4.1%) were not statistically significant. With itraconazole pulse 68.22% Aspergillus spp, 50.0% Fusarium spp and 84.6% Penicillium spp showed clinical cure, while terbinafine pulse cured 55.0% Aspergillus spp and 50.0% Fusarium spp. CONCLUSIONS: NDM was the prevailing fungi in onychomycosis in Sri Lanka. Both itraconazole and terbinafine were partially effective on NDM onychomycosis showing a clinical cure of 54-65%. Future research should focus on searching more effective antifungal for NDM onychomycosis.

Randomized, double-blind, controlled, comparative study on intralesional 10% and 15% hypertonic saline versus intralesional sodium stibogluconate in Leishmania donovani cutaneous leishmaniasis.

BACKGROUND: Intralesional 7% hypertonic saline (HS) has been shown to be effective and safe against Leishmania donovani and Leishmania major cutaneous leishmaniasis (CL), with cure rates of 92% and 96%, respectively. This study was designed to assess the efficacy and safety of 10% and 15% HS in CL. METHODS: A total of 444 patients (643 lesions) were randomly allocated to sodium stibogluconate (SSG), 10% HS and 15% HS at a ratio of 2 : 2 : 1, taking into consideration any unwanted side effects that might arise with 15% HS. The follow-up period was 18 months. Survival analysis using Cox proportional hazard regression was performed to assess the effectiveness of the three treatment modalities. The clinical trial was registered at the Sri Lanka Clinical Trial Registry (SLCTR/2013/024). RESULTS: Treatment with SSG resulted in a cure rate of 96.3% within one to seven injections (mean: 3.6 injections); the mean (median) duration of treatment was six weeks (6 weeks) per lesion. Treatment with 10% HS showed a cure rate of 93.0% within one to 10 injections (mean: 5.28 injections); the mean (median) duration of treatment was 9.3 weeks (9 weeks) per lesion. Treatment with 15% HS showed a cure rate of 93.6% within two to 10 injections (mean: 5.3 injections); the mean (median) duration of treatment was 11.3 weeks (10.0 weeks) per lesion. Treatment with 10% HS and 15% HS caused cutaneous necrosis in 3.1% and 30.6% of lesions, respectively. Despite continuous data collection for 14 months, we were unable to recruit a sample of sufficient size. Seventeen (3.8%) patients were lost to follow-up, and 24 (5.4%) were partial or non-responders. CONCLUSIONS: This study found 10% HS to be an effective and safe alternative to SSG. Treatment with HS at concentrations of 15% or above was not safe as a result of cutaneous necrosis. Safety was not studied for concentrations of 11-14%, and these concentrations should be avoided pending further evidence. Hypertonic saline is very cheap (< US$1 per 100 ml, whereas SSG is priced at US$160 per 100 ml), is prepared locally and has no systemic side effects and minimal local side effects.

Liquid nitrogen cryotherapy on Leishmania donovani cutaneous leishmaniasis.

OBJECTIVE: To evaluate the efficacy and the safety of liquid nitrogen cryotherapy (LN) on Leishmania donovani cutaneous leishmaniasis and on type V skin. METHODS: LN was applied to 65 patients (121 lesions) using cotton swabs attached to ekels. Cryosessions were performed for 15-20 seconds, two per site, weekly for 1-3 weeks, fortnightly for 4-5 weeks and then monthly until cure. Patients were followed-up for 6 months after cure. RESULTS: A total of 91.7% of patients were cured within one to seven cryosessions; mean 3.57. With one to four cryosessions, papules ≤ 1 cm in diameter showed rapid healing (90.5%) in comparison with those of > 1 cm diameter (64.28%). The cure rates for lesions on the head (84.61%) and upper limb (82.6%) were greater than those for the lower limbs (71.42%) and trunk (66.66%). With LN, local pain lasted for 15-30 minutes; ulceration (33%), depigmentation (46.9%) and scarring (43%) were noticed. During 6 months of follow-up there was one (1.6%) recurrence. CONCLUSIONS: LN (77.15% cure within one to four cryosessions) is an alternative to intralesional sodium stibogluconate in the treatment of papules measuring ≤ 1 cm. In type V skin, LN should be avoided on the face, and on patients who have a tendency to form keloids. We recommend giving cryotherapy using cryoguns (instead of cotton swabs attached to ekels) fortnightly (not weekly), which may minimize ulceration, and therefore scarring.

Clinico-histopathological correlation and the treatment response of 20 patients with cutaneous tuberculosis.

Cutaneous tuberculosis (TB) can mimic other granulomatous diseases clinically and histopathologically. This case series relates images and workup of 20 patients who were histopathologically and therapeutically confirmed to have cutaneous TB. Although positive results of ESR, Mantoux reactivity, and TB cultures facilitate the clinical diagnosis, negative results should not exclude the diagnosis of cutaneous TB. An alternative cause should be considered if the clinical response to anti-TB drugs is inapparent within 2 months.

Randomized, double-blind, comparative clinical trial on the efficacy and safety of intralesional sodium stibogluconate and intralesional 7% hypertonic sodium chloride against cutaneous leishmaniasis caused by L. donovani.

INTRODUCTION: Since cutaneous leishmaniasis (CL) is a self healing disease, an ideal therapy should be rapidly effective, easily administered, cheap, available at all times at all centers and should have no side effects. OBJECTIVES: To determine the efficacy and safety of intralesional 7% hypertonic saline in comparison to intralesional sodium stibogluconate against L. donovani CL. METHODS: Intralesional hypertonic saline (HS) and sodium stibogluconate (SSG) were randomly allocated to 154 patients (229 lesions); these were followed-up for 18 months. RESULTS: The M:F ratio was 1.8:1 (99:55). The average age of our population was 32 years. SSG was given to 87 patients (136 lesions); HS was given to 67 patients (93 lesions). SSG showed a 100% cure rate within one to six injections (average 3.24); HS showed a 92.2% cure rate within one to 10 injections (average 5.27). The average duration of treatment with SSG and HS was 5.11 and 8.78 weeks respectively. There was no difference in efficacy for both therapies with regard to ulcers or papules, and small or large, exposed or unexposed lesions. There was no association between the rapidity of clinical response and the duration and location of lesions. There were no local or systemic side effects except pain during injection. The lesions in the two groups showed post-inflammatory hyperpigmentation after treatment. During 18 months of follow-up there were no recurrences and no visceralization. CONCLUSIONS: The most effective therapy for Leishmania donovani cutaneous leishmaniasis was intralesional SSG (average 3.24 injections). HS was effective, but needed an average of 5.27 injections in total per lesion. HS was cheap, with no risk of systemic side effects and was easily available at all centers.

Dapsone-induced haemolytic anaemia, hepatitis and agranulocytosis in a leprosy patient with normal glucose-6-phosphate-dehydrogenase activity.

A 21 year old boy with borderline lepromatous leprosy and normal glucose-6-phosphate-dehydrogenase activity developed haemolytic anaemia, hepatitis and agranulocytosis following 19 weeks of multi-bacillary multi-drug therapy. With early administration of antibiotics and G-CSF our patient recovered without residual complications. All patients taking dapsone should be warned to discontinue the drug immediately in the event of fever, chills and sore throat occurring within the treatment period until further investigations are performed.