A Brief Review on Infestation of Cutaneous Leishmaniasis in Pakistan

Cutaneous leishmaniasis frequently including only the skin and one and more than one lesions are present on the skin depending on the species of Leishmania , smooth ulcers, flat plaques, nodules or hyperkeratosis wart like ulcers may be observed. The causative agent of cutaneous leishmaniasis is L. tropica which is spreading by Phlebotomus sergenti, P. papatasi, P. caucasicus, P. longipes and P. pedifer in the endemic areas. According to WHO, annually 0.4 million new cases of leishmaniasis occur per year, approximately with almost 400 million people at threat of the disease. The infection is commonly present along the entire Western border of Pakistan. Sindh (area associated with Balochistan), Punjab (Multan and Chakwal) and Northern Areas of Balochistan. In Pakistan, the status of leishmaniasis has been changed. In parts of the country both the cutaneous and the visceral types of the disease are being noticed from various parts of the country, including Khyber Pakhtoonkhwa. This articleis focus on the burden of CL in different areas of Pakistan.


Introduction
Leishmaniasis is a vector transmitted disease caused by more than 25 obligatory intracellular protozoans belonging to Leishmania; a genus of flagellate protozoa (order: Kinetoplastida, suborder: Trypanosomatidae) are parasites with worldwide distribution, several species of which are pathogenic for humans Barral [1] Cox [2]. The causative agent of cutaneous leishmaniasis is L. tropica which is spreading by Phlebotomus sergenti, P. papatasi, P. caucasicus, P. longipes and P. pedifer in the endemic areas. The sand flies are obligatory vectors and insect hosts of Leishmania species Cotran et al, [3].
More than 80 countries of the World cutaneous leishmaniasis (CL) are found. Yearly frequency of 1.5 million cases per year reported by WHO Sharma,et al. [4]. Out of 350 million people, it is projected that 12 million people are infected from a population who are at risk Sharma, et al. [4]. Most cases of CL are present in Saudi Arabia, Afghanistan, Syria, the Americas and Iran. In Pakistan the case of both cutaneous and visceral leishmaniasis are found.
2.7% prevalence rate has been reported from the Northwestern region of the country. Occurrence in Pakistan has been anticipated at 4.6 cases/1000 persons/per annum from the last ten years Kolaczinski, et al. [5]. The parasites of leishmaniais are found in all over the World except Antarctica and Australia Magill [6]. The infection is commonly present along the entire Western border of Pakistan. Sindh (area associated with Balochistan), Punjab (Multan and Chakwal) and Northern Areas of Balochistan Ahmad, et al. [7].
In Pakistan two species of Old World CL are endemic to Pakistan.
Leishmania major cause ZCL or Rural or Wet, is associated with bites of P. papatasi and present in rural areas of Pakistan Faulde, et al. [8]. Zoonotic cutaneous leishmaniasis is endemic to the Southwest, mainly occurring in Balochistan, neighbouring Punjab and Sindh provinces Burney [9]. Dry type leishmaniasis has a widest distribution, occurring in urban areas of Southern Punjab (Multan) and Balochistan (Quetta) but also focally in the Azad Kashmir and Northern Areas Khan [10].
In Pakistan, the status of leishmaniasis has been changed. In parts of the country both the cutaneous and the visceral types of the disease are being noticed from various parts of the country, including Khyber Pakhtoonkhwa Khan [11]. A study was conducted on CL by Ullah, et al. [12] in Dir Upper. The samples were collected The second effected part of body noticed in the study was hand (26.5%). Most of the lesions were dry (81%). The survey of Durrani, et al. [13] shows that both dry and muco-purulent cutaneous forms of the disease were found to be endemic in the North, South and West of Pakistan. The East and Southeastern regions were non endemic. No case of visceral form of disease was encountered during the period of study from any part of the country.
In Northern Pakistan the disease was most prevalent in humans in November 2007 (661) and least prevalence rate was noticed in February, 2008 (292), while in dogs the highest prevalence was during November, 2007 (24%) and lowest prevalence in January, 2008 (5%). In Southern Pakistan the highest human disease prevalence was observed in April, 2008 (518 cases) and lowest disease prevalence was noticed in June, 2007 with 308 cases. A research was carried out on CL in Peshawar by Nawaz, et al. [14].
In the survey out of 229 peoples 19 were Afghan refugees and 276 were from local population in 16 (5.79%) were positive for CL. High prevalence rate (10.9%) was noticed in the age of 0-9, followed by the age group 10-19 (6.66%). Face was highly infected. In majority of cases (9.5%) one lesion were noticed while 5.62% had 2 to 3 lesions, 5% had 4 to 5 lesions and 4% had more than 5 lesions.     [20] reported two types of CL, ZCL and ACL found to overcome in Balochistan Khan [21]. Khan [22] conducted a study on CL in Hospitals at Peshawar during January to May, 2002 and recorded that CL is a rising health problem of the country. 16 patients were reported positive for CL out of 167 male patients and 6 female cases were positive among 139 female individuals. 236 cases were detected by Kolachi, et al. [23] in Taluka Juhi, district Dadu. Total 108 cases were determined as CL.
Children and women were highly effected. Kakarsulemankhel [24]    cases of CL were reported by Mujtaba [35]

in Nishtar Medical
College Multan during 1995-97. Only dry types of lesions were noticed. All of the patients were infected by L. tropica. Out of 120, 90 cases reported as positive for CL in the study of Nawab, et al. [36] diagnosed in Dr. Ihsanullah's Lab., Karachi. Cutaneous leishmaniasis cases were observed by Ahmad (1988) in southern Balochistan and its association as a zoonosis. Ghazi [37] [40,41] in the out-door department of Nashtar Hospital, Multan.

Conclusion
From the article it is revealed that CL is present in most of the areas of Pakistan. The most infected areas of Pakistan are present in Baluchistan and Khyber Pukhtoonkhwa. Those areas are very infected where Afghan refugees are present. It is concluded that the CL is a very sever threat for the public health of Pakistan.