Am. J. Trop. Med. Hyg., 85(2), 2011, pp. 193–194 doi:10.4269/ajtmh.2011.11-0128 Copyright © 2011 by The American Society of Tropical Medicine and Hygiene Images in Clinical Tropical Medicine Post-Kala-Azar Dermal Leishmaniasis in Mymensingh, Bangladesh Shamim Islam, M. Ashraful Alam Bhuiyan, and Caryn Bern* Children’s Hospital and Research Center Oakland, Oakland, California; ICDDR,B, Dhaka, Bangladesh; Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia A 50-year-old man from Mymensingh district, Bangladesh, presented with a 3-month history of non-pruritic, painless hypopigmented papules, and plaques, beginning on the face and subsequently spreading to the forearms, torso, and legs (Figures 1–4) Fifteen months before the onset of skin lesions, Figure 2. Hypopigmented papules are seen on the patient’s back. The lesions are roughly symmetrical, a common characteristic of postkala-azar dermal leishmaniasis (PKDL), and are painless and nonpruritic. the patient had visceral leishmaniasis (kala-azar), successfully treated with 30 intramuscular injections of sodium stibogluconate (SSG). Polymerase chain reaction showed Leishmania donovani DNA in a buffy coat specimen. Post-kala-azar dermal leishmaniasis (PKDL) is a chronic skin rash usually seen in apparently cured kala-azar patients in East Africa and South Asia. In the Indian subcontinent, Figure 1. The patient has hypopigmented papules and plaques scattered over the face, most concentrated peri-orally and on the cheeks, common areas of involvement for post-kala-azar dermal leishmaniasis (PKDL). The patient consented to having his picture published in the journal. *Address correspondence to Caryn Bern, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, MS F-22, 4770 Buford Highway NE, Atlanta, GA 30341. E-mail: cxb9@cdc.gov Figure 3. Hypopigmented papules on the abdomen. 193 194 ISLAM AND OTHERS the cumulative PKDL incidence after kala-azar is 5–10%.1 The PKDL usually presents with erythematous or hypopigmented papules or macules, sometimes progressing to plaques or nodules. Kala-azar patients treated with antimonial drugs may have poorer immune recovery and a higher risk of subsequent PKDL compared with those treated with amphotericin formulations.2 The only PKDL treatment regimens with proven efficacy in South Asia consist of 120 SSG injections over 6 months or miltefosine 2.5 mg/kg/day for 12 weeks. The PKDL patients are infectious to the sand fly vector and are thought to represent an important parasite reservoir in the anthroponotic transmission cycle of visceral leishmaniasis in South Asia.1 Received March 4, 2011. Accepted for publication April 25, 2011. Authors’ addresses: Shamim Islam, Children’s Hospital and Research Center Oakland, Oakland, CA, E-mail: sizuba@yahoo.com. M. Ashraful Alam Bhuiyan, ICDDR,B, Dhaka, Bangladesh, E-mail: aabhuiyan@ icddrb.org. Caryn Bern, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, E-mail: cxb9@cdc.gov. REFERENCES Figure 4. The patient has hypopigmented papules and plaques on both forearms. The absence of sensorineural changes helps to distinguish post-kala-azar dermal leishmaniasis (PKDL) from leprosy, which commonly presents with hypopigmented macules or patches associated with hypoesthesia or anesthesia, and neural thickening. 1. Rahman KM, Islam S, Rahman MW, Kenah E, Chowdhury MG, Zahid MM, Maguire J, Rahman M, Haque R, Luby SP, Bern C, 2010. Rising incidence of post kala-azar dermal leishmaniasis in a population-based study in Bangladesh. Clin Infect Dis 50: 73–76. 2. Saha S, Mondal S, Ravindran R, Bhowmick S, Modak D, Mallick S, Rahman M, Kar S, Goswami R, Gaha SK, Pramanik N, Saha B, Ali N, 2007. IL-10- and TGF-beta-mediated susceptibility in kala-azar and post-kala-azar dermal leishmaniasis: the significance of amphotericin B in the control of Leishmania donovani infection in India. J Immunol 179: 5592–5603.