Emerging leishmaniasis in southern Himalayas: A mini-review

Table 1 Findings of published articles on leishmaniasis in southern Himalayas w.r.t. agent-host-environment details

Ref.	Sample size	Location (if available district, state, country)	Agent factors	Host factors	Vector identified	Environmental factors	River body associated	Authors conclusion
Katakura et al[4]	> 1000	Different areas of Pakistan, India, and Nepal	In Pakistan Himalayas, Leishmania tropica followed by Leishmania major	CP: Cutaneous leishmaniasis (CL) cases only; No descriptions	In all Himalayas, P. sergenti followed by P. argentipes and papatasi	Altitude is not documented	Indus, Ganges	Microsatellite analysis of the parasites will be a powerful tool for population genetic and epidemiological studies of Leishmania species
				Rx: Not known
			In India, L. donovani followed by L.tropica	Outcome: Not known
			In Nepal, L. major
Rab et al[5]	239 (1984-1992) and more cases in the past (before 1984)	Different areas of Northern areas of Pakistan (Bagh, Abbottabad, Chilas, and Baltistan)	Leishmania	Clinical presentation (CP):	Not documented	Altitude is not documented	Indus	The clinical pattern of VL in north Pakistan is akin to that in north-western China, with a marked predilection for young children, and a male preponderance. The infantile VL has risen 10-fold in the last decade from 0.2 to almost 2 per 100 000 population
				Visceral leishmaniasis (VL – all cases); Not described
			infantum	Rx: Not known
				Outcome: Not known
Wani et al[6]	18	Different areas of Uri &Karnah belt, Jammu & Kashmir, India	Leishmania, species not identified	CP: Cutaneous leishmaniasis (CL); mostly nodulo-ulcerative, mostly on the face and single lesion	Not documented	Altitude is not documented. The hot and arid climate of these areas(Uri belt) is quite conducive to the growth and development of leishmania and the sand fly	Not documented	Any patient with nodular/nodulo-ulcerative lesion on exposed parts must be suspected for CL, especially if belonging to the Uri and Karnah region of the Kashmir Valley. The public health authorities should make every effort to contain this new infection in this Valley
				Rx: Intravenous sodium
				Stibogluconate including two received intra-lesional
				Outcome: Survival for all cases
Leherwal et al[7]	Three	Uri belt, Jammu & Kashmir, India	Leishmania, species not identified	CP: Cutaneous leishmaniasis (CL); solitary erythematous nodule on the face	Not documented	Altitude is not documented	-do-	Focuses on the diagnostic part. FNAC may be the method of choice for suspected CL in cases of solitary nodular lesions
				Rx: Not documented
				Outcome: Not documented
Mahajan et al[8]	One	Uri in South West Kashmir, Jammu & Kashmir, India	Leishmania, species not identified	CP: Visceral leishmaniasis (VL); 2months fever, weight loss, ascites, anemia, Hepato-splenomegaly,	Not documented	Altitude is not documented	-do-	This advice for further research into the epidemiology, geographic distribution, and inter-species interactions of the parasite
				Rx: Intravenous sodium
				Stibogluconate
				Outcome: Survived
Sharma et al[9]	285	Nirmand village,Shimla & Kullu Districts of Himachal Pradesh, India	Among 14 cases, Leishmania tropica (3) and Leishmania donovani (11)	CP: CL; mostly nodulo-ulcerative, mostly on extremities	Among 41 cases, P. longiductus (29), P. major(8), P. kandelaki (2), and 2 remained unidentified	Altitude is not documented	Satluj river	Different leishmania species and vectors compared to other parts of India are found in these Himalayas
			Tissue smear positivity for amastigotes was 43%	Rx: Intra-leisonal sodium		The climate of the affected areas varies from temperate to subtropical
				Stibogluconate
				Outcome: Survival for all cases
Sharma et al[10]	161 new localized cases of LCL from May 2001 and December 2003	sub-alpine valley in the mountainous region of the Kinnaur District,Himachal Pradesh, India	L. donovani in eight cases and L. tropica in two cases	Histopathology showed non-caseating epitheloid cell granuloma in 77% of the cases. Lesions involved mainly the face	Phlebotomus longiductus is a possible vector	Altitude, 700-2,900 m above sea level	Satluj River	Intralesional sodium stibogluconate was effective in all patients
Raina et al[11]	18	Shimla, Kinnaur & Kullu Districts of Himachal Pradesh, India	Leishmania, species not identified	CP: VL - prolonged fever, weight loss, ascites, pancytopenia, hepato-splenomegaly, lymphadenopathy, diarrhea, and epistaxis	Not documented	Altitude, 924 - 2960 m above sea level	Satluj and Beas river	Initial failure to suspect VL in this area might cause a diagnostic delay
				Rx: Intravenous sodium				There is a favorable therapeutic response without recurrence of symptoms during 6 months of follow-up
				Stibogluconate		The patients had never visited any of the endemic areas
				Outcome: 14 Survives and 4 deaths
Thakur et al[46]	Cases of CL During 2014–2018 in the study area	case reports came from Districts of Kinnaur, Shimla, and Kullu and the previously nonendemic districts of Mandi and Solan,Himachal Pradesh, India	L. donovani variants distinct from the viscerotropic L. donovani strain from northeast India	Coexistence of VL and CL	Not documented	Not documented	Not documented	The scenario appears somewhat similar to Sri Lanka and Kerala, where L. donovani parasites cause cutaneous disease, albeit with differences in the region-specific L. donovani variants
Thakur et al[47]	Sixty CL patients over the period from 2014 to 2018	Satluj river belt in Himachal Pradesh, Khaneri/rampur (location of medical college),Himachal Pradesh, India	Presence of L. seymouri co-infection in the unusual CL cases in Himachal Pradesh (HP) caused by L. donovani variants	Coexistence of VL and CL	Not documented	Not documented	Satluj river	Found the presence of Leptomonas seymouri in 38.5% (22/57) of the patients along with L. donovani detected in all the samples. L. seymouri is a monoxenous insect trypanosoma, generally incapable of infecting humans
Sharma et al[49]	None	Shimla, Kinnaur, &Kullu Districts of Himachal Pradesh, India	Not applicable	Not applicable	Among 62 cases, Phlebotomus longiductus (46), P. major (8), P. kandelaki (8)	Our patients reported having been out of the state or district during the three years the preceding onset of symptoms	Satluj river	Phlebotomus longiductus may be the primary vector for human leishmaniases in this endemic focus, however, it needs another study to prove the vector species corresponding to the type of leishmania species

Table 2 Characteristics of Leishmaniasis in the southern Himalayan region

Sr No.	Geographical area	Causative agent	Vector	Clinical picture
1	Northern areas of Pakistan[2]	LeishmaniaInfantum	Not identified	Visceral leishmaniasis
2	Indian states of Jammu & Kashmir[3-5]	Not identified	Not identified	Cutaneous leishmaniasis most common with a single case study of visceral Leishmaniasis
3	Himachal Pradesh[6-16]	L. donovani & L. tropica	P. longiductus (most common) & P. major	Both cutaneous & visceral forms ofLeishmaniasis
4	Uttarakhand (Garhwal)[17-21]	L. donovani	P. argentipes	Visceral leishmaniasis
5	Uttarakhand (Kumaon)[22-25]	Not identified	P. argentipes	Visceral leishmaniasis
6	Nepal[26-29]	L. donovani	P. argentipes	Visceral leishmaniasis
7	Bhutan[30,31]	L. donovani	P. argentipes	Visceral leishmaniasis