CC BY
4TREATMENT OF PATIENTS WITH CUTANEOUS LEISCHMANIASIS IN THE REPUBLIC OF UZBEKISTAN
1Rizayev J.A., 2Azizov B., 3Egamov S.X.
1,2,3Samarkand State Medical University https://doi.org/10.5281/zenodo.10240699
Abstract. Skin leishmaniasis (Pendian ulcer, cutaneous leishmaniasis of the Old World -Borovsky's disease, cutaneous leishmaniasis of the New World, chancre of the Sahara, Biskra's bud, oriental ulcer, uglevik, yearling, Sart disease, Ashgabat ulcer) is an endemic vector-borne disease characteristic of countries with hot and warm climates, manifested predominantly by skin lesions [1].
There are four main clinicalforms of the disease: cutaneous leishmaniasis, mucocutaneous leishmaniasis, diffuse cutaneous leishmaniasis and visceral leishmaniasis [3]. Cutaneous leishmaniasis is a favorable form and accounts for 50-75% of all cases of the disease [2,4].
Keywords: ulcer, leishmaniasis, uglevik, mineral water, tonic
The purpose of the research: study of clinical-immunological (clinical-therapeutic) features of cutaneous leishmaniasis in patients.
Research materials: the process of treatment of patients with leishmaniasis.
Results.
Depending on the method of treatment, two groups were defined: I - 70 patients who received traditional treatment; II - 64 patients who received our proposed treatment method, which included: Mupiroban ointment followed by the application of Fatiderm cream. The composition of Fatiderm includes activated silicon water tonic "ASW-Fatiderm", 150 ml - organic mineral water, consisting of complexes of siliceous minerals of Uzbekistan SiO2 (36 mg/l), Na (319 mg/l), K (13 mg/l), Ca (28 mg /l), Fe (0.3 mg/l), Co (0.0002 mg/l), Ni (0.002 mg/l, as well as Au, Tb, Sm, Dy, Gd, Er, Ho, Tm.pH -7.9
Thanks to its unique composition, the tonic activates the processes of regeneration of skin cells and mucous membranes, has antioxidant and tonic properties, helps reduce the inflammatory process and reduce the level of colonization of microorganisms in lesions, restores the natural pH of the skin, and increases the therapeutic effect of external medications.
Directions for use: Activated silicon cream "Fatiderm" is used for external use, applied by rubbing onto skin lesions. It is recommended to use 2-3 times a day. The duration of use depends on the condition of the mucocutaneous process. Recommended for use by people of any age.
Traditional therapy included etiopathogenetic agents in accordance with the standards for the treatment of leishmaniasis (gentamicin, doxycycline and local treatment) in accordance with the age of the patients, individual reactivity, drug tolerance, depth and extent of the pathological process.
Mupiroban ointment was applied to a cleaned, dried ulcer after treatment with a 3% hydrogen peroxide solution, after 30 minutes Fatiderm cream was applied. Appropriate treatment was carried out 3 times a day until etiological recovery. In cases where deep ulcerative lesions were noted after etiological recovery, Fatiderm cream was used to help accelerate the healing of ulcers.
According to clinical forms, patients were distributed according to the classification of P.V. Kozhevnikova: ulcerated leishmaniomas without complications - 59 patients 44%, leishmaniomas with lymphangitis and lymphadenitis - 40 patients 30%, leishmaniomas with tubercles of contamination - 21 patients 15.5%, combined specific complications - 14 patients 10.5%, respectively. Consequently, in both study groups, patients with an ulcerated form of dermatosis predominated, and specific complications were diagnosed in groups I and II - in 8 patients 6% and 6 patients 4.5%, respectively.
The distribution of patients by gender and age. In group I, men and women made up 75 and 56.5%, and in group II - 59 and 44%, respectively.
In terms of age, patients were distributed as follows: up to 10 years - 11 and 8.2%; 11-20 years old - 33 and 24.6%; 21-30 years old - 43 and 32%%; 31-50 years old - 35 and 26.1%; 51 and older - 12 and 8.9%, respectively. Thus, the largest number of patients in both groups were males aged 21-30 years and the smallest number of patients was registered in the group under 10 years of age.
The majority of the patients we examined lived for a year or more in endemic areas of Samarkand, Jizzakh and Syrdarya regions. Therefore, in our patients it was not possible to accurately determine the incubation period of the disease. From the anamnesis, most patients initially noted the appearance of bright red rashes the size of a pea or larger on various parts of the skin, accompanied by slight itching and swelling. The process progressed quickly and ulceration occurred within 2-3 weeks. In the center of the rash, point necrosis occurred with the formation of a dense dark crust on the surface. When the crust was removed, the bottom of the ulcer had a whitish appearance with a slight serous discharge. Leishmanioma increased in size due to the disintegration of the surrounding infiltrate. In some patients, due to peripheral growth, leishmaniomas merged with each other and formed large lesions with abundant purulent-necrotic discharge.
The duration of the disease was: 7-30 days - 41 patients 30.5%; 31-45 days - 63 patients 47%; 46-60 days - 30 patients 22.3%, respectively. Thus, in both groups, the largest number were patients with a duration of cutaneous leishmaniasis of up to 45 days.
When examining the patients, ulcerative skin lesions of oval or irregular shape were discovered. The bottom of such ulcers was deep, whitish and grayish in color with serous-purulent exudate.
In some cases, the purulent-necrotic exudate dried out, and the entire ulcer was covered with a grayish-brown, brownish-purulent crust. The edges of the ulcers were most often sharply cut, scalloped, less often undermined, although not along the entire length. The ulcer was surrounded by a peripheral specific infiltrate of red color with a bluish tint, sharply demarcated from healthy skin. In most cases, the infiltrate had a ridge-like smooth or tuberous rim with a width of 3 to 10 mm, and, only with small ulcers, the dimensions reached 20-30 mm. Towards the outside, the infiltrate descended more gently than towards the center. The consistency of the infiltrate was moderately dense, doughy, and its surface was usually covered with a small number of thin scales. In some patients, small and large additional foci of necrosis were observed in the rim of the infiltrate, visible through the epithelium in the form of slightly yellowish dots. Depending on the state of the marginal infiltrate and the ulcer itself, a boil-like nodular infiltrate with a small central abrupt ulcer, often covered with a crust, was observed, as well as, most often, an ulcer with a smooth infiltrated edge, usually oval, without rough scalloping, in shape. In this
case, the marginal infiltrate up to 10 mm wide was covered with smooth, tense, sometimes shiny epithelium. At a later stage of the disease, ulcers with a granular or bumpy marginal infiltrate up to 4 mm in size were recorded. The edges of the ulcers were scalloped, and there were tubercles of contamination around the leishmanioma.
In the patients we observed in both groups, the maximum number of leishmaniomas per patient did not exceed 9. The total number of ulcers in all patients in groups I and II was 267 and 259, respectively.
On average per patient in group I. accounted for 3.71, and in group II. - 3.56 ulcers. 15 and 11.1% of patients had one leishmanioma, 23 and 17.1% had two, 46 and 34.3% had three, 28 and 20.8% had four, 22 and 16 had from five to nine. .4% of patients, respectively, in groups I and II. Thus, the largest number of patients had up to 5 ulcers and in group I were 41%, and in group II -42.5%.
The localization of ulcerative lesions was different (Table 6): on the head - 5.2 and 6.7%, on the neck and torso - 15.2 and 10.5%, on the upper extremities - 42 and 45.5%, on the lower extremities - 37.6 and 37.3%, respectively, with traditional treatment and in the main group. Consequently, the majority of leishmaniomas were found on the upper and lower extremities.
The localization of leishmaniamas had a certain influence on the clinical picture and course of leishmaniasis. Leishmania ulcers on the face were deep and prone to rapid growth. Large leishmaniomas with scanty purulent discharge and a weakly expressed specific infiltrate were found on the body. Ulcerative lesions with copious purulent discharge and thick purulent crusts were localized in the area of the legs and feet, accompanied by edema and lymphangitis. Rapid growth and mild trauma were characteristic of leishmaniomas on the forearms and hands. On the hands, as a result of injury from leishmania, diffuse infiltrates formed, covering the entire back of the hand and spreading to the forearm. When the fingers were affected, the latter thickened, became stiff, and persistent crack-like ulcers were noted on the joints. When leishmaniases' were localized near the nail plates, persistent leishmania felons were observed, accompanied by severe pain.
The number of clinical forms of the disease that occur with specific complications is increasing. Thus, with a duration of dermatosis of 7-30 days in patients of both study groups, no symptoms of lymphangitis or tubercles of contamination were noted, whereas with a disease duration of 31-45 and 46-60 days, specific complications were recorded in group I in 28.9 and 100%, and in II - 31.4 and 100% of patients, respectively.
According to our study, specific complications in the form of lymphangitis and lymphadenitis were diagnosed in 16.7% of patients in group I and 19.8% in group II. Of these, 9.7 and 12.7% were men in groups I and II, and 7% were women, respectively. According to the age composition, patients in groups I and II were distributed as follows: up to 10 years - 0 and 1.4%, 11-20 years - 1.4% each, 21-30 years - 4.2 and 2.8%, 31 -50 years old - 8.3 and 12.7%, over 50 years old - 2.8% each, respectively. Thus, lymphangitis and lymphadenitis most often occurred in patients over 30 years of age.
Lymphangitis was predominantly localized on the upper and lower extremities, and the maximum number of them was in the areas of the hands and forearms, as well as the legs and feet. From the upper edge of the ulcer or slightly higher in the subcutaneous tissue, dense nodes ranging in size from a small pea to a hazelnut, round or oval in shape, well demarcated from the surrounding tissues, mobile, and slightly painful, were palpated. Their consistency in the initial
period was always hard, the skin over large nodes was slightly stretched, of normal color with a slight shine. With a superficial location under the skin, the nodes are clearly visible to the eye and are located at a distance of 1-3-5-7 cm from each other, and the largest nodes are usually located near leishmaniomas, and small ones at a further distance. In cases of a clear-shaped appearance, from the upper edge of the ulcer or slightly higher, the lymphangitis was directed upward along the course and branching of the superficial vessels, forming branches and cords with nodules. In patients with a long course of PCL, the nodes were enlarged, immobile, adherent to the skin, pasty in consistency and painful, the skin over them was blue-red in color. The patients we examined were also diagnosed with lymphangitis in the form of single nodes, which were nodes the size of a pea to a cherry, located in the subcutaneous tissue at a distance of 2-3 cm from the leishmanioma. In addition to these types of damage to the lymphatic vessels, cord lymphangitis was noted. In this case, cords or large cords from 0.5 to 1.5 cm in diameter and from 3 to 10 cm in length extended from the ulcer in the subcutaneous tissue; On palpation they were of a dense consistency, well demarcated from the surrounding tissues, and not fused to the skin. When leishmaniomas were localized in the area of the fingers, hands and forearm, lymphangitis began above the upper edge of the ulcer, directed upward to the forearm and shoulder, following the course and branching of the superficial lymphatic vessels. With leishmaniomas in the area of the feet and legs, lymphangitis stretched upward in the direction of the lymphatic vessels, and, not reaching 5-7 cm to the inguinal nodes, disappeared. Combinations of various types of lymphangitis were also noted. Thus, one patient was diagnosed with bead-shaped, cord and single nodes. On the upper and lower extremities, especially when ulcers were localized on the hands or feet, multiple lymphangitis, consisting of 2-3 branches, was usually recorded, often leading to swelling of the underlying sections. We did not observe lymphangitis with ulceration.
Among the examined patients, specific complications in the form of tubercles of contamination occurred in 11.1% of patients in group I and 14.1% in group II. Of these, men accounted for 5.6 and 8.5% in groups I and II, and women - 5.6% each, respectively. With a disease duration of 31-45 days, tubercles of contamination were recorded in 8.3 and 8.5% of patients, and with 46-60 days - 2.8 and 5.65% of patients, respectively. Tubercles of contamination were located superficially, under the skin, or in the dermis itself along the periphery of leishmania at a distance of 0.5-1-3-5 cm, the size of a hemp grain and in rare cases up to a large pea, dense consistency, dark red color with a shiny surface , located in numbers from 3 to 10 or more isolated from each other, sometimes in groups with the formation of a focus with a lumpy surface of a dark red color.
REFERENCES
1. Скрипкин Ю.К. Кожные и венерические болезни. Руководство для врачей: в 4 т. Под ред. Ю.К. Скрипкина. М: Медицина 1995; (1): 422—454.
2. Латышев Н.И., Крюкова А.П. Роль большой песчанки в хранении вируса кожного лейшманиоза в течение межэпидемического периода. Доклад Академии наук СССР 1941; XXX (1): 90—92.
3. Фицпатрик Т., Джонсон Р., Вулф К., Полано М., Сюрмонд Д. Дерматология. Атлас-справочник. 3-е изд. М: Практика 1999.
4. Родионов А.Н. Дерматокосметология. Поражение кожи лица и слизистых. Диагностика, лечение и профилактика. СПб: Наука и Техника 2011.
5. Blum G., Desjeux P., Schwarz E. et al. Treatment of cutaneous leishmaniasis among travellers. J Antimicrob Chemother 2004; 53: 158—66.
6. Hengg U.R., Marini A. Cutaneous leishmaniasis. Hautarzt 2008; 59: 627—32.
7. Кожевников П.В. Проблемы кожного лейшманиоза. Ашхабад, 1941.
8. Арифов С.С. Клиническая дерматология и венерология Атлас, Ворис-Нашриёт, Ташкент-2008, 272-273.
9. Azizov B.S., Karimova MK, Nabiev FH An Atypical Case of Leishmaniasis with HIV Co-Infection. Dermatology Case Reports.- Vol.2(3). 12, 2017.P. 134.- USA.
