Ethics statement

The study was approved by the human ethics committee of Rajendra Memorial Research Institute of Medical Sciences, Agamkuan, Patna. Written informed consent was obtained before collecting the samples.

Case

A Forty eight year-old male patient from Bahorchak, Begusarai district of Bihar, had been suffering from hypopigmented skin lesions on his face and limbs for 18 months. He visited nearby traditional healer with this dilemma, but due to lack of proper counselling and medication, the situation of the skin lesions remained the same. The patient had a VL history about 12 years ago and during that time he had received Sodium Antimony Gluconate (SAG) at a dose of 20mg/kg/body weight for one month. He was referred by a local clinician to ICMR- Rajendra Memorial Research Institute of Medical Sciences, Agamkuan at Patna, Bihar, India. He visited to our outdoor patient department (OPD) on 21^st August 2017. He was observed with nodular lesion on his chin and severely ulcerated lesions spread at the other parts of his body (Fig 1). On the physical examination, papulo-nodular skin lesions were found to be spread all over his body parts especially on his face, upper torso and on his upper and lower limbs. His lesions were found non-itching with intact sensitivity.

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Fig 1. Different stages of PKDL appearance in the patient at pre-treatment and end of the treatment.

https://doi.org/10.1371/journal.pntd.0008052.g001

Methods and materials

The patient then clinically diagnosed as PKDL positive with rK39 (InBios International, Inc. Seattle, USA) strip test followed by qPCR. Furthermore, the blood sample was collected for hematological and biochemical examinations, skin biopsy and Real Time PCR were performed to demonstrate the presence of Leishman-Donovan (LD) bodies and acid-fast bacilli (AFB). The Leishman-stained slit skin smear (SSS) was prepared from papulo-nodular skin lesions at the chin region of the patient, stained with Giemsa which was found to be positive (5+) for LD bodies (Fig 2A) [1, 2]. The skin biopsy was also performed with Ziehl Nielsen stains for AFB in order to detect leprosy which was found to be negative.

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Fig 2.

(A) Microscopic picture of LD bodies (5+) (B) Here Ct value is inversely proportional to Parasitic Load in pre treatment and end of the treatment. Parasitic load was found to be high in the pre-treatment condition as compared to the post treatment condition.

https://doi.org/10.1371/journal.pntd.0008052.g002

Results

A support in this notion came from qPCR which was found to be positive for Leishmania donovani (Fig 2(B)). A lower Ct value was observed in qPCR at pre-treatment condition whereas a higher Ct value was observed in the post treatment condition. As the parasitic load is inversely proportional to the Ct value, the result depicts that treatment with miltefosine results parasite clearance from the highly ulcerated patient.

Discussion

The chronic PKDL lesion is a well known dermatosis, often harbour parasite in the skin and plays a crucial role in the inter-epidemic communication for VL. The severe occurrence is immunologically intervened within the lesion [4, 5]. The skin lesions appear generally following treatment VL, after 2–3 years and in some cases, these lesions emerged even after a period of 10 years [6]. In this case report, the lesions exceeded the upper limit of time period for the appearance of PKDL. Our in vitro results demonstrated the presence of Leishmania donovani in skin slit smear. Though several PKDL cases appeared after the treatment of either AmBisome, miltefosine or other conventional drugs, but appearance of such ulcerated skin is rare. Therefore, we measured the level of CD4 as well as CD8 T cell at pre-treatment and at the end of the treatment. Previous studies also demonstrated the crucial role of CD8 T cell in immuno-pathogenesis with spectator of tissue damage [7, 8]. Furthermore, an exuberated CD8 T cells play vital role in immuno-pathogenesis and disease severity in PKDL as well as in other form of Leishmaniasis [7]. Indeed, patients suffered with PKDL, cutaneous and muco-cutaneous Leishmaniasis exhibited a significant increase in IL-10 producing CD8 T cell population which directly corroborate with disease pathogenesis [9, 10]. In corroboration with the previous studies, an elevated level of CD8 T cell at pre-treatment level is thought be involved in the highly ulcerated skin. Miltefosine is currently being used as anti-parasitic oral drug for treating PKDL which can easily accessible and safe to use [11, 12]. Previous study also demonstrated the treatment with miltefosine for 12 weeks (50 mg twice per day) has a cure rate of 93% (per protocol [PP] analysis) [13]. In Indian subcontinent, PKDL cases are treated according to national guidelines with miltefosine for 12 weeks with miltefosine. Interestingly, with the treatment of Miltefosine (50 mg twice per day for 84 days), the ulcerated skin became normal with reduced inflammation. Notably, during the treatment, no major alteration in biochemical as well as haematological parameters was observed (S1 Table). This report illustrates the success of treatment with miltefosine in treating highly ulcerated PKDL case without any severe complication. However, the adverse events described earlier are well-known and manageable with very minimum treatment facilities at the community level. Moving forward, this study will be useful to the medical practitioner as well as the policy makers to treat the severe ulcerated PKDL with Miltefosine.

Supporting information

Acknowledgments

We are highly thankful to the study participant to provide his consent and enthusiastically participated in this study. We also thank Mrs Mary Shanti Grace Thithio, Mr Devender Prasad Yadav, Mr. Rajender Kumar, Ms. Surya Suman, Mr. Tathagat Gupta and Mrs. Rakhi Kumari for their valuable inputs.