American University of Beirut Medical Center,Beirut
After earning his MD from Damascus Medical School in 1999, Dr. Ibrahim Khalifeh completed a surgery internship (2000-2001) and pathology residency (2001-2002) at American University of Beirut Medical Center. In 2002, he left for the USA where he did four years of training in Pathology and Laboratory Medicine at Wayne State University in Detroit (2002-2006), Oncologic Pathology and Cytopathology fellowships at MD Anderson Cancer Center (2006-2008) then he joined the University of Alabama where he completed one year of fellowship in Dermatopathology (2008-2009). Dr. Khalifeh is a diplomat of the American Board of Anatomic and Clinical Pathology, Cytopathology and Dermatopathology. He joined the Department of Pathology and Laboratory medicine at AUBMC in 2009 as assistant professor. He has been involved in multiple projects related to cutaneous leishmania, melanoma, dysplastic nevi and BRAF.
Background: Cutaneous leishmaniasis (CL), a potentially chronic and disfiguring condition, has been thrust in to the spotlight following reports among military personnel returning from the Near East. Lebanon (LB), a non-endemic area, is now suffering a health care crisis in the wake of a CL epidemic brought from endemic Syria by the protracted conflict in the region, resulting in the displacement of over 1,500,000 refugees into LB.
Materials and Methods: Punch biopsies (1 patient sampled/displaced family, n=158) were taken for histologic examination (parasitic index) and molecular speciation by PCR. Demographics, migration patterns, lesion number and characteristics including presence of extensive disease (ED) were documented. ED was defined as having ≥1 of the following: Disfiguring, threatening the function of vital sensory organs, lesion present for >12 months, >3cm, ≥5 lesions and special forms of CL (i.e. sporotrichoid).
Results: 1275 refugees with CL fled from endemic and non-endemic areas alike, had been in LB 5 months on average and 77% of them reported the appearance of the first lesion after being in LB for > 2 months (average incubation period 2-8 weeks). Of the 158 sampled patients, PCR resulted in 135 cases of L. tropica and 23 L. major types. In this special conflict population, the preponderance of patients sampled were under 18 years old (80%) and an average of 52% members were affected/family (mean number of members = 6). The majority of patients met criteria for ED (59%) including: 27.3% with disease compromising a sensory organ, 9% special forms, 37.3% disfiguring, 49% >3cm, 20% > 5 lesions and 9% chronic lesions. Parasitic index, molecular subtype and geographic location were similar for ED versus non-ED. ED was more prevalent among children (median 9 vs. 21 years; p=0.002) and was more frequently observed on the face and lower extremities (p=0.002). Both age and anatomic location were predictors of ED by multivariate logistic regression. 82% of the cases had initial cure after treatment.
Conclusion: In studying this epidemic, we are seeing a new face of CL in times of war; stressful and unsanitary living conditions may account for the uncharacteristically high number patients with ED. Furthermore, the majority of patients reported appearance of lesions well beyond average documented incubation periods for CL suggesting the transfer and propagation of CL to LB and other non-endemic countries harboring refugees.