Cutaneous leishmaniasis in Afghanistan

Abstract

Old World cutaneous leishmaniasis (OWCL) is a sand fly-transmitted skin infection caused by Leishmania species that extends from West Africa to China. Afghanistan probably has the highest burden of OWCL and is home chiefly to Leishmania tropica and Leishmania major, which cause anthroponotic and zoonotic CL, respectively. Although data on the species distribution in Afghanistan are patchy, L. tropica predominates over L. major, reflecting its concentration in large cities. CL prevalence in Afghanistan increases with increasing age to peak at 5-10 y, depending on the local epidemiology. Clinically, there is a spectrum of lesions common to both main species with nodules, ulcerated nodules and papules accounting for the majority (50-80%) of lesions at presentation. When healed, CL lesions leave pale scars that often have deleterious psychosocial effects. Leishmania control involves vector control and treating patients, but these are severely challenged by decades of war and disruption to the health system. In the public sector, only injectable antimonials, sodium stibogluconate or meglumine antimoniate, are available and, anecdotally, efficacy remains high. Few clinical trials have been conducted in Afghanistan and data support antimonial efficacy; small clinical series suggest good efficacy of oral miltefosine against the two main species. Herein, we focus our review on the epidemiological and clinical aspects of CL in Afghanistan and suggest avenues of future research.

Keywords: Afghanistan; Kandahar; cutaneous; leishmaniasis; treatment.

Figure 1.

Global status of cutaneous leishmaniasis (World Health Organization, 2021).

Figure 2.

Afghanistan's provinces. ^*maps-of-the-world.net/maps/maps-of-asia/maps-of-afghanistan/large-administrative-divisions-map-of-afghanistan-2008.jpg (accessed May 2024).

Figure 3.

The two main rodent reservoirs of Leishmania major. The great gerbil, Rhombomys opimus (left), and the Libyan jird, Meriones libycus (right). File: Rhombomys opimus 2.jpg—Wikimedia Commons, accessed 18–3–23. (Image—Meriones libycus (Libyan Jird) | BioLib.cz, accessed 18–3–23 ‘The resized photographs can be freely used on any pages for non commercial, scientific and educational purposes, if you let me know about it first.’ Permission to publish obtained from K. Rudloff.)

Figure 4.

The trends in clinically diagnosed anthroponotic and zoonotic cutaneous leishmaniasis reported through the national system in 2023 for the whole of Afghanistan.

Figure 5.

Reported cases of cutaneous leishmaniasis in the provinces of Afghanistan, 2003–2016^*. ^*Control of cutaneous leishmaniasis in Afghanistan: achievements and challenges 2018. https://www.who.int/publications/i/item/who-wer9317.

Figure 6.

Trend of anthroponotic and zoonotic cutaneous leishmaniasis in Afghanistan reported through the national system from 2019 to 2023.

Figure 7.

A positive leishmaniasis microscopy slide from an Afghan patient.