Zoonotic Cutaneous Leishmaniasis, Afghanistan

To the Editor: Recent reports from Afghanistan have focused on the current status of war-and refugee-related anthroponotic cutaneous leishmaniasis (ACL), caused by Leishmania tropica, in Kabul City, refugee camps, and Fayzabad City (Badakhshan Province) (1–4). In central Asia, ACL is transmitted mainly by the sandfly Phlebotomus sergenti in urban or peri-urban environments (5). Zoonotic cutaneous leishmaniasis (ZCL), caused by L. major, occurs autochthonously in Afghanistan, but little is known about its regional and seasonal distribution or other disease characteristics (6,7). Recently, cases have been reported in troops deployed to the Mazar-e Sharif area: 19 cases among the British military contingent in 2004, 186 among Dutch troops in 2005 (overall attack rate 20.9%), and 14 among German troops in 2005 (8). This yet-undescribed L. major variant is highly aggressive, often disseminates and causes nodular lymphangi-tis, and is associated with delayed or poor response to treatment with sodium stibogluconate or miltefosine. Regional epidemiologic reports, when available from Afghan or international health authorities, usually mention cutaneous leishmaniasis cases without further elaboration. To evaluate the current threat and specific epidemiology of cutaneous leish-maniasis in Mazar-e Sharif, medical entomologic and epidemiologic field investigations were conducted in June and October 2005. Results show that ZCL, ACL, and visceral leishmaniasis (VL) are endemic to Mazar-e Sharif. Data from patients seeking treatment were ACL, and 2 (0.05%) were VL; the number of unreported cases during this time is unknown. A sharp increase (4.4-to 5.4-fold) in ZCL cases was found when data from July 21 through August 20 and from August 21 through September 20, 2004, (30 and 169 cases, respectively) were compared with data for the same periods in 2005 (163 and 744 cases, respectively). ZCL chiefly affects farmers, nomads, and refugees. By sex, cases occurred in 1,991 (52.6%) male and 1,791 (47.4%) female patients. By age group, the rate for ZCL in young children was similar to that for other age groups: 1,167 (30.9%) cases in children <4 years of age, 1,218 (32.2%) cases in children 5–14 years of age, and 1,397 (36.9%) cases in persons >15 years of age. In the leishmaniasis center, cutaneous infections are confirmed by seeing Leishmania parasites in Giemsa-stained smears obtained directly from skin lesions. Although sporadically confirmed by culture and PCR, ZCL and ACL are usually differentiated by specific clinical aspects, especially of skin lesions: dry lesions characterize urban ACL; wet lesions, often super-infected and disseminating, characterize rural ZCL. In terms …