A Mirror of Hospital Practice

^EYE COMPLICATIONS OF DERMAL LEISHMANIASIS

By L. EVERARD NAPIER, f.r.c.p. (Lond.) E. O'G. KIRWAN, c.i.e., m.d., B.ch., f.r.c.s.i.

LIEUTENANT-COLONEL, I.M.S.

and

G. SEN, m.b. (Cal.), d.t.m.

Mohi Uddin, male, aged 20 years, was admitted on 7th July, 1939, to the hospital attached to the Calcutta School of Tropical Medicine. He gave no history of

kala-azar, but a vague history of some undiagnosed fever in childhood. Nodules began to appear on

different parts of his body about five years ago.

Present condition.?He had a distinct reddish flush of his cheeks and chin, and at times, after exposure to the sun, his whole body showed this flush. He had

typical post-kala-azar dermal-leishmaniasis nodules and depigmented areas all over his face and body. Those on his face, and especially those at the skin-mucous- membrane junctions, were smooth reddish bullous nodules, soft and rubbery to feel, but formed of solid

though loose-textured tissue. The eyelids were involved in these swellings, his eyes were watery, and he kept them half closed (vide plate XXXI, figures 2 and 3); also, he had photophobia. A nodule was removed from his chin; a smear made

from the cut surface of this nodule showed abundant leishmania. Both cornea; showed numerous opacities; the right

had a pannus all round the periphery, and the left was almost completely opaque from the nodular growth covering half of it. There was marked vascularization. The vision in the left eye was almost nil but improved to 'counting fingers at one metre'; in the right eye vision was only sufficient for him to walk alone with

difficulty, but it improved to 3/60. He was sent to the eye hospital on 20th September,

1939: at this time the eye condition was as follows:?

Both upper eyelids are somewhat thickened, but the lower eyelids are normal. The palpebral conjunctive are not involved, and the bulbar conjunctiva; are only affected in the vicinity of the limbi. The cornea; show a diffuse haziness, multiple opacities,, marked pannus extending all round the periphery, deep vascularization and infiltration into the substantia propria.

The most striking point is1 the presence of nodule? in the vicinity of the limbi and these have sprea superficially to form a pannus and deeply to form a, interstitial keratitis. Vascularization is very marke '

and as the disease has progressed it has gradua1 > extended around the cornese. The sclera approximate the cornea is involved in part and the disease ?>a

probably originated from here as an episcleritis. .

The ciliary body and iris are very slightly involve^ there are some posterior synsecliire but no evidence o

active inflammation. There is no anaesthesia and very little pain. The left eye is more affected than to

right eye. The clinical picture might on first examination 0

>,

confused with trachoma or leprosy, if it were not 1?

the presence of typical post-kala-azar dermal-lel?j. maniasis nodules on the patient's face and body, on closer observation the appearance is very differ?11,' Blepharospasm, photophobia and epiphora althoug present were not marked signs. Treatment.?He was given potassium iodide, gr- ^

'

t.d.s.; the dose was gradually increased until by tj1 18th day he was taking gr. xxx, t.d.s., which dose A

took for 14 days. On the 24th day of the iodide c?i1Il0 he was given neostibosan 0.3 g. every other day up g 12 doses. After a further month's interval he ^va

given urea stibamine, doses up to 0.2 g., on alterna days for 12 doses. .

g During the interval, one or two isolated no"^|C

were injected with 2 per cent berberine sulphate. ?

injected nodules shrunk slowly but did not disappea1- Progress.?After a month of potassium iodide, ^

patient felt very ill and his face was swollen. fL improved immediately the iodide was discontinued, was noticed that the lesions were slightly reduced.

After the second course of antimony the skin con"1 tion was distinctly better and he left hospital. ...

Re-admission.?He was re-admitted on 6th July, l^y '

the nodules had by then nearly disappeared (figure but his sight was still poor and he was anxious to h?v further treatment with the idea of improving this- Figure 1, plate XXX, shows the condition of the eyes

at this time. *

He was again sent to the eye hospital with a reque ̂ that the growth over his cornea should be remove for examination for the presence of Ieishmania. . j The large diffuse nodule on the left eye was incise

at the limbus and a small piece of the inflammat^e tissue removed. Smears from this tissue showed tn

presence of Ieishmania.

Plate XXX

Ay

?&_.. ?

Keratitis due to dermal leishmaniasis.

R.E. L.E.

Fig. 1. Fig. 1.

Keratitis due to dermal leishmaniasis.

R.E. L.E.

Plate XXXI

S \1

Fig. 2.?Showing: condition on first admission. Fi" 2.?Showing condition on first admission.

Fia;. 3.?Showing condition on first admission. Fi<r. 3.?Showing condition on first admission.

Fig. 4.?Showing condition at time of re-admission.

Fig. 4.?Showing condition at time of re-admission.

Fig. 5.?Showing condition on final discharge. Fig. 5.?Showing condition on final discharge-

Sept., 1941 ] AN INTERESTING CASE OF MALARIA : MITRA 543

stikreatment.?He was given 20 injections of amino-

to Jffi' each, on alternate days from 7th August \t 1 ?e.Pternber, when he was discharged.

i\v._ time of discharge his sight was much further lmP.roved (figure 5).

?On the 20th September, 1939, the vision

E. 3/60: L. E. 1/60

^ treatment on the 20th July, 1940, the vision

E. 6/36: E. E. 2/60

Comment.?This was a fairly typical case of . ?st-kala-azar dermal leishmaniasis;* in Bengal, aj

"as been calculated (Napier, 1931) that 0ut 5 per cent of persons suffering from kala-

tj^ar, .eventually develop the local lesions. If

r0 .story is correct the patient recovered from 0 visceral infection without any specific treat-

ofent; this is not unusual, for about 25 per cent j. Patients with this condition give a similar

ag .0ry- The bullous lesions are not seen

frequently as the ordinary nodular lesions, a I

^is patient also showed, but are not rare, ^ the photo-sensitive flush is quite common,

tli 01}ly uncommon feature in this case was ^condition of the eyes.

inf ? re^erence in the literature to leishmanial

suh-Ctlons 6^e aPPear to be rare. On the

(jqogC^ .

?f leishmanial keratitis, Duke-Elder in his well-known textbook writes :?

ThP?rnea^ involvement by Leishmania is very rare,

by ^?de of infection is not proven, but it is probably oCci ?ct inoculation from the fingers: it does not

corj,1 ,ln. Persons who have had the disease, and the

Tjje ]? ^faction confers subsequent general immunity. 1929)C olca^ .P^ture produced is characteristic (Chams, Phot . a.rting with irritative symptoms of pain, phi 0Phobia and lacrimation, a superficial erosion or a

^vhieti ^e efflorescence appears on the comea,

I l^pkly associated with a deep infiltration.

Centr m 'tration pervades the entire cornea, in the

or which an abscess forms, which in the? 3rd

the w?ek discharges itself either exteriorly or into

loss a? ri?r chamber, the result being blindness, or

tion f ? e^e- Treatment should be by the applica- atr0D-? antiseptics, as methylene blue with

cautp^e' .combined with general arsenical treatment:

Scars riZTaf^?n involves the formation of unusually dense of {V it is undertaken energetically before the end

g0od e 2nd week the prognosis as regards the eye is

is rfp'i lie fair vision may be retained: if its inception Caso- a^e,d until the 4th week more than half of the

0 end in perforation.'

but^6 ^ave n?t consulted the Chams reference, inf ^FesuiPably he refers to Leishmania tropica corfr ??n' secondary to oriental sore. In this

of ^Jon auto-inoculation is a recognized mode

,otS^ad of the infection. Oriental sore does

the ?CCUr *n Bengal and this patient never left

due ?r?v*nce. In this case the skin condition is

don ai^ hematogenous infection of Leishmania the ?Van^- In this form of dermal leishmaniasis

tion assumPtion is that the wide distribu-

the leishmania takes place at the time of thp Vls<?eral infection when the parasites are in

Peripheral blood. Whilst the dermal lesions n? reach the clinical threshold at the

tharf 1Tloment, for some develop more slowly cror? ?^ers, they do not appear in successive

* s> there is no evidence that extension

from the earlier lesions ever takes place, and the question of auto-inoculation need not be considered as the lesions are non-ulcerative. As the cornea is a non-vascular tissue, the leish- mania cannot have been there from the time of the visceral infection and in this case extension from the sclera must have taken place, as occurs in tuberculous episcleritis. The response of the dermal lesions to treat-

ment was characteristically slow, but, as is

usually the case, the condition was eventually cured, and in this instance the eye lesions also showed considerable improvement and possibly after a lapse of time these will have improved further, but we have now lost track of this

patient. Had this condition been left untreated, we

do not anticipate that it would have followed the course described by Duke-Elder, for neither ulceration nor abscess formation occur in post- kala-azar dermal leishmaniasis (L. donovani

infection), whereas the former is the rule in

oriental sore (L. tropica infection); it is however probable that the infiltration and vascularization of the cornea would have proceeded further and eventually produced complete blindness.

fe

REFERENCES

Napier, L. E. (1931) .. Indian J. Med. Res., 19, 1.

Duke-Elder, W. S. (1938). A Textbook of Ophthal- mology, 2. Henry Kimp- ton, London.