Br J Ophthalmol: first published as 10.1136/bjo.52.6.481 on 1 June 1968. Downloaded from http://bjo.bmj.com/ on November 27, 2023 at Pakistan:BMJ-PG Sponsored.

Brit. J. Ophthal. (1968) 52, 481.

CUTANEOUS LEISHMANIASIS (OREENTAL SORE)*t

A CASE WITH CORNEAL INVOLVEMENT

BY

J. E. CAIRNS
Cambridge

PROTOZOA of the genus Leishmania cause at least three distinct diseases. All are trans-
mitted by the bite of sandffies of the genus Phlebotomus. The diseases are Kala azar
(visceral leishmaniasis) due to L. donovani, cutaneous leishmaniasis (oriental sore) due to L.
tropica, and muco-cutaneous leishmaniasis (South American leishmaniasis) due to L.
brasiliensis.
Oriental sore, or cutaneous leishmaniasis, tends to occur in local areas, and has accumu-

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lated a host of names such as Baghdad boil, Jericho boil, Aleppo boil, Delhi boil, and
Quetta sore. It is endemic in India, Pakistan, Iran, Iraq, Syria, Turkey, S. Russia, the
Mediterranean littoral, Abyssinia, the Sudan, Nigeria, and China (Hargreaves and
Morrison, 1965).
The clinical picture of cutaneous leishmaniasis is characterized by the appearance of small
papules on the exposed areas of skin. These enlarge and become scaly, and the crusts fall
off to leave suppurating sores, which usually become surrounded by oedema (wet type).
However, a dry indolent lesion is also common. A relapsing, chronic form, clinically very
similar to lupus vulgaris, has been described as leishmaniasis recidivous. Secondary sores
may form around the primary lesion or infection may be transferred to remote situations
by scratching (Chams, 1930). Healing usually takes place within one year, but occasionally
may last longer and some lesions have remained active for 30 years. Scarring and cicatriza-
tion may be extensive, and eyelid deformities are common. Direct involvement of the
cornea has rarely been reported (Donatelli, 1950; Gandolfi, 1952; Pestre, 1955; Scuderi,
1947), although corneal exposure due to lid deformities is not uncommon (Duke-Elder,
1965). In leishmaniasis due to L. brasiliensis direct corneal involvement, rare as it is,
appears to be more common (Dusseldorp, 1928; Carvalho, 1935; Spinola, 1937; Marback,
1953).
Treatment consists of parenteral administration of sodium stibogluconate (Pentostam
B.W.), and amphotericine B (Fungizone, Squibb) has been demonstrated as an effective
treatment in cases resistant to the antimalarial drugs. However, local infiltrations of the
lesions with 10 per cent. mepacrine, 1 per cent. berberine sulphate, 2 per cent. emetine have
all been used with some degree of claimed success (Hargreaves and Morrison, 1965).

* Received for publication March 9, 1967.

t Address for reprints: Byron Lodge, Harston, Cambridge.
481
 Br J Ophthalmol: first published as 10.1136/bjo.52.6.481 on 1 June 1968. Downloaded from http://bjo.bmj.com/ on November 27, 2023 at Pakistan:BMJ-PG Sponsored.
482 J. E. CAIRNS
Case Report
A 17-year-old Sikh patient, who had left the Punjab at the age of 134 years and had lived in England ever
since, came to the Eye Clinic complaining of pain in the right eye for the last 6 days.
Examination.-Deep and superficial keratitis with a mild anterior uveitis were noted. The left cornea
appeared to be normal. A scaly lesion was noted over the right malar region (Fig. 1). The patient said
that this lesion had been present for 5 or 6 years and was now increasing in size. A biopsy of this lesion
showed Leishman-Donovan (L-D) bodies and a diagnosis of cutaneous leishmaniasis was made.

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FIG. 1.-Lesion of cutaneous leishmaniasis before FIG. 2.-Lesion of cutaneous leishmaniasis after
treatment. treatment by intra-lesional injections of mepacrine
10 percent.

Treatment and Progress.-During this period the keratitis was becoming severe and the visual acuity was
reduced to 5/60, in spite of treatment with atropine and steroid drops. Treatment of the skin lesion by
infiltration locally with 10 per cent. mepacrine solution was followed by rapid flattening of the area of the
eruption (Fig. 2). Over the same period the keratitis became completely inactive and visual acuity returned
to 6/6. A few areas of white scarring in the stroma remained (Fig. 3).

Discussion
This case is interesting in that it appears to demonstrate the somewhat unusual complica-
tion of keratitis due to L. tropica and the extremely chronic nature of the skin lesions due to
this organism. The patient had been outside the range of the insect vector for over 3 years.
It is also of interest that the keratitis, which was of a severe character, subsided as the skin
lesion became inactive (Andrade, 1942). Finally, such a case serves as a reminder that this
condition must be considered as a cause of keratitis in any patient who has been in an
endemic area during the past two or possibly three decades and who has a chronic granulo-
matous skin lesion anywhere on the body, especially in an exposed area.
 Br J Ophthalmol: first published as 10.1136/bjo.52.6.481 on 1 June 1968. Downloaded from http://bjo.bmj.com/ on November 27, 2023 at Pakistan:BMJ-PG Sponsored.
CUTANEOUS LEISHMANIASIS 483

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FIG. 3.-Corneal lesion at the stage of scarring.

I am indebted to Professor F. Kerdal Vegas for his advice and encouragement, to Prof. Barrie Jones for
his evaluation of the case, to my colleague Dr. Arthur Rook for Figs 1 and 2, to the Departments of Medical
Illustration at the Institute of Ophthalmology, London, and Addenbrooke's Hospital, Cambridge.

REFERENCES
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DONATELLI, G. (1950). Rass. med. (Milano), 27, 139.
DuKE-ELDER, S. (1965). "System of Ophthalmology", vol. 8, Part I, p. 398. Kimpton, London.
DUSSELDORP, M. (1928). Arch. Oftal. (B. Aires), 3, 288.
GANDOLFI, C. (1952). Arch. Ophtal. (Paris), 56, 59.
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Press, London.
MARBACK, H. (1953). "Les6es oculares da leishmaniose tegumentar Americana". Manu, Bahia.
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SCUDERI, G. (1947). Rass. ital. Ottal., 16, 335.
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