A Retrospective Study on Human Cutaneous Leishmaniasis (CL) and First Report on Visceral Leishmaniasis (VL) from Islamabad, Pakistan During 2012-2023
Sundas Zahra1, Wajiha Ali1, Huma Khan1, Ahmareen Khalid2, Asma Khattak2,
Nida Khan3, Minahil Attiq1, Guo-Jing Yang4,5, Rana Muhammad Kamran Shabbir6 and Haroon Ahmed1*
1Department of Biosciences, COMSATS University Islamabad, Park Road, Chak Shahzad, Islamabad, Pakistan
2Department of Pathology, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
3Department of Medicine, Lady Reading Hospital, Peshawar, Khyber Pakhtunkhwa, Pakistan
4Key Laboratory of Tropical Diseases Control, National Health Commission of Peoples Republic of China, The First Affiliated Hospital of Hainan Medical University, Hainan Medical University, Haikou, Hainan, P.R. China.
5Key Laboratory of Tropical Translational Medicine of Ministry of Education and School of Tropical Medicine and Laboratory Medicine. R.P. China
6Department of Zoology, Division of Science and Technology, University of Education Lahore, Punjab, Pakistan
ABSTRACT
In Pakistan, leishmaniasis is the second most common disease after malaria and is a neglected tropical vector-borne illness that affects public health globally. No previous epidemiological investigation of human leishmaniasis has been reported in Islamabad, Pakistan. Therefore, the current study aimed to determine the prevalence of human leishmaniasis for the first time in the study area. The current retrospective study was conducted on suspected cases of human leishmaniasis reported in Pakistan Institute of Medical Sciences (PIMS) Hospital, Islamabad, during the years 2012-2023. All epidemiological and pathological information’s were collected. For statistical analysis, the chi-square (χ2) test was applied, and a p value <0.05 was considered significant. A total of 290 suspected cases of human leishmaniasis were reported, and 87.2% (253/290) were confirmed positive, comprising 97.3% (247/253) cutaneous, 2% (5/253) mucocutaneous, and 0.4% (1/253) visceral leishmaniasis cases. The highest frequency of positive cases was observed in November 2012 (6.2%, 18/290), followed by March 2013 (5.2%, 15/290). The majority of leishmaniasis cases were recorded in the age group 21-30 (24.5%), followed by age groups 31-40 (14.5%) and 11-20 (13.8%), respectively. Gender-wise findings revealed that the number of males (48.9%) were higher as compared to females (38.3%). In addition, the majority (98.6%, 286/290) of the cases had only one lesion formation, and the most frequent lesion sites were skin (42.8%, 124/290) followed by the face and head areas (28.9%, 84/290). The current findings revealed an increase in the frequency of human cutaneous leishmaniasis in Islamabad during 2012 and 2023. However, further epidemiological, and serological studies are required to determine the prevalence of human leishmaniasis in Pakistan.
Article Information
Received 28 January 2024
Revised 05 April 2024
Accepted 18 April 2024
Available online 08 July 2025
(early access)
Published 24 March 2026
Authors’ Contribution
SZ, WA, HK performed the data collection, its documentation, analysis, and AHK and ASK assisted in the data collection and methodology section. HA and GJY supervised the study. NK, MA and RMKS critically review and revised the manuscript. All authors read and approved the final manuscript.
Key words
Leishmaniasis, Cutaneous leishmaniasis, Mucocutaneous leishmaniasis, Visceral leishmaniasis, Human, Pakistan
DOI: https://dx.doi.org/10.17582/journal.pjz/20240128153014
* Corresponding author: [email protected]
0030-9923/2026/0003-1103 $ 9.00/0
Copyright 2026 by the authors. Licensee Zoological Society of Pakistan.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
INTRODUCTION
Leishmaniasis, a group of vector-borne diseases, is caused by a eukaryotic protozoan parasite of genus Leishmania that belongs to the family Trypanomastidae (Roatt et al., 2020) and around 20 species of Leishmania are known to cause leishmaniasis in humans (Cecílio et al., 2022; Seaman et al., 1996). This parasite is transmitted through the bite of infected female phlebotomine sandflies that sucks blood of the host (Kayani et al., 2021). Based on the causative Leishmania species, its location and immune response of the host, there are three major types of leishmaniasis, cutaneous (CL), mucocutaneous (MCL) and visceral (VL) leishmaniasis (Burza et al., 2018). CL displays single to multiple skin ulcers, lesions, or nodular lesions, MCL affects mucosal membranes and the VL involves infection of internal organs, such as the liver, spleen, and bone marrow, and it is lethal if not treated appropriately (Burza et al., 2018; Chappuis et al., 2007; Pearson and Sousa, 1996).
Leishmaniasis is considered a global public health issue and is one of the seven neglected tropical diseases worldwide according to World Health Organization (WHO Reports, 2023; de Souza et al., 2018). It is one of the most unrecognized tropical diseases, endemic in 98 countries around the world and estimated 350 million people at risk globally (Mcgwire et al., 2014; Jorjani et al., 2019). Approximately 0.2 to 0.4 million cases of VL and 0.7 to 1.3 million cases of CL are reported annually, with an estimated 20,000 deaths per year (Alvar et al., 2012). The 90% of VL cases are mostly reported from Bangladesh, Brazil, India, Kenya, Somalia, South Sudan, and Ethiopia (Hailu et al., 2016; Alvar et al., 2012) and 95% of CL cases occur in the Mediterranean basin, the Middle East, South America, and Central Asia (Torres-Guerrero et al., 2017; WHO, 2023). In 2018, over 85% of new CL cases reported to the WHO were from Afghanistan, Algeria, Bolivia, Brazil, Colombia, Iran, Iraq, Pakistan, Syria, and Tunisia (WHO, 2020; Moein et al., 2018). In Pakistan, around 21,700–35,700 cases of cutaneous leishmaniasis are reported annually (Alvar et al., 2012). CL is endemic in regions of Pakistan including Baluchistan, Punjab, and both CL and VL in Khyber Pakhtunkhwa (KP) (Alvar et al., 2012; Khan et al., 2019, 2021; Hussain et al., 2018). Moreover, the number of cases reported in non-endemic areas of Pakistan are also increasing due to massive migration from endemic areas of country and abroad (Kassi et al., 2008). CL has two main forms; an anthroponotic form caused by Leishmania tropica mostly found in urban areas while zoonotic form caused by Leishmania major is found in rural areas of Pakistan (Afghan et al., 2011).
The formation of small erythema on site of bite is the first sign of leishmaniasis infection and due to inflammatory response, it develops into an open ulcer or visceral lesion (Thakur et al., 2020). CL causes formation of one or more ulcerated lesions on exposed body parts (Pearson and Sousa, 1996) including face, forearms, legs, and areas where sand-fly bites usually occur (Ahmed et al., 2019; Al-Dhalimi et al., 2023). The Leishmania parasite goes through morphological changes (amastigotes and the promastigotes) each time it transfers between the host and the vector (Mandell et al., 2022). In all diagnostic methods for leishmaniasis, parasitological methods are mostly preferred, and common parasitological test is histopathology, an in vitro examination of the tissue or skin of suspected lesion, in which skin and mucosal parts are stained to detect presence of parasite (de Vries et al., 2015). Moreover, microscopical diagnosis includes the staining of smears for confirmation of Leishmania amastigotes in the affected tissues aspirates, smears, or biopsies (de Vries et al., 2015; Boelaert et al., 2007). The most appropriate antileishmanial treatment has not been asserted since various species of Leishmania display different symptoms (Kotb and Agil, 2015). Although many treatments are available, only chemotherapy has been found to be satisfactory for treating leishmaniasis (Croft and Coombs, 2003). Pentavalent antimonial have been used as first-line treatments against leishmaniasis disease for almost seventy years (Frézard et al., 2009; Torres-Guerrero et al., 2017) but due to its adverse effects its use as a treatment is affected (Llanos-Cuentas et al., 2008; Freitas-Junior et al., 2012).
CL is a neglected disease because of its low mortality, so people do not take preventive and control measures seriously, resulting in an increase in its incidence worldwide (Reithinger et al., 2007). Considering the increasing prevalence of CL in various parts of Pakistan, it is crucial to provide immediate healthcare support and public awareness campaigns for proper prevention of its further spread around the country (Sajjad et al., 2022). Epidemiological studies and information regarding leishmaniasis are also insufficient in Pakistan (Khan et al., 2016).
There is paucity of data on leishmaniasis in both endemic and non-endemic regions of Pakistan. Previously, only few a studies have been conducted in Pakistan’s endemic regions, such as Baluchistan (Khan et al., 2021), KP (Naz et al., 2022), Punjab (Khan et al., 2016), and other locations of Punjab (i.e. Waziristan) (Hussain et al., 2018). To the best of our knowledge, this is the first epidemiological study that was designed to investigate histopathological assessed suspected cases of human leishmaniasis in Islamabad, Pakistan, reported during the years 2012-2023.
MATERIALS AND METHODS
Study area
This study was conducted in Islamabad (33°49’ N, 72°24’ E), Pakistan. Islamabad city has a total area of 906.50 square kilometers, with both urban and rural regions; the urban area is 220.15 sq. km, and the rural area is 466.20 sq. km. It is located on northern region of Pakistan featuring a subtropical humid climate, cold winters, and hot, humid summers along with monsoon season (CDA, 2022). Studies have shown that the northern and western regions of Pakistan have higher prevalence of CL while VL is endemic in regions with mountain and farming communities (Tazerji et al., 2022). The data required for this study was retrieved from Pakistan Institute of Medical Sciences (PIMS) Hospital in Islamabad.
Study design
The current retrospective study was carried out over a six-months period from July 2023 to December 2023. A total of 290 suspected cases of human leishmaniasis were included in the study, which were registered in the PIMS hospital during 2012-2023. The patient data were retrieved from the Pathology Department of the PIMS Hospital, Islamabad, with the department head’s explicit consent
The data included the following variables for epidemiological investigation; gender, age, month, year of reported cases, diagnostic tests used, number of lesions, lesion localization and pathological findings of each patient.
Clinical features
The suspected cases were evaluated using histopathology test and Fine Needle Aspiration Cytology (FNAC) test. Pathological findings of these reports confirmed CL in most of the cases, but few reports lacked specification of type of leishmaniasis (CL, MCL, or VL). We found few cases suspected to have MCL and VL leishmaniasis since their pathological characteristics resembled the mucocutaneous and visceral type of human leishmaniasis according to World Health Organization report (WHO, 2020).
Statistical analysis
The data was documented into MS excel sheets and statistically analyzed using SPSS software (version 26). The chi-square test was applied for statistical analysis and a p value <0.05 was considered significant. Frequency of variables like year, month, age, gender, number of lesion and their localization, diagnostic tests, and pathological findings of all patients were calculated using formula; Reported cases/ Total cases *100. Prevalence was calculated for confirmed positive cases of CL and suspected cases of MCL and VL by year, age, and gender, using the formula: Positive cases/ Reported cases *100.
RESULTS
In the current study, 290 suspected cases of human leishmaniasis were reported between February 2012 and July 2023 in PIMS hospital, Islamabad, of which 87.2% were confirmed positive (97.6% CL, 2% MCL, and 0.4% VL) and 12.8% were negative. The frequency of positive cases was higher among males (48.9%) compared to females (38.3%). The overall prevalence rate was 87.2% (253/290), and the average percentage of positive cases reported in the past 12 years was 7.8% (Fig. 1).
Year wise distribution
The highest number of positive cases was observed in the year 2013 (17.2%), and the percentage subsequently decreased significantly until 2021 (0.3%). The lowest frequency was observed during the years 2019-2021, and the reason might be the masking effect of the COVID-19 outbreak in these years. After the year 2021, a sudden increase has been observed in the percentage of positive cases from 1.4% in 2022 to 2.4% in 2023 (Fig. 1). This sudden rise in the number of positive cases suggests an increase in the prevalence rate of leishmaniasis in Islamabad, Pakistan. The statistical analysis showed a significant association among different years (p <0.05) (Table I).
Month wise distribution
The highest frequency of positive cases was observed in the month of November 2012 (6.2%) (Fig. 2a), followed by March 2013 (5.2%) (Fig. 2b), and December 2012 (3.8%) (Fig. 2a). The study observed a varied distribution of positive cases in each month of each year (2012-2023). However, from 2012-2023, February had the highest frequency (14.1%), followed by March at 13.4% with the second highest positive cases. Moreover, the lowest frequency was observed in the month of October, with 2.4% positive cases.
Table I. Year wise distribution and prevalence of human leishmaniasis.
|
S. No |
Year |
Total cases |
Positive (%) |
Negative (%) |
Prevalence (%) |
Statistical analysis |
|
1 |
2012 |
41 |
39 (13.4) |
2 (0.7) |
95.1 |
χ2 = 179.407 d.f = 11 p = 0.00 |
|
2 |
2013 |
54 |
50 (17.2) |
4 (1.4) |
92.6 |
|
|
3 |
2014 |
50 |
44 (15.2) |
6 (2.1) |
88 |
|
|
4 |
2015 |
45 |
35 (12.1) |
10 (3.4) |
77.8 |
|
|
5 |
2016 |
32 |
29 (10.0) |
3 (1.0) |
90.6 |
|
|
6 |
2017 |
30 |
24 (8.2) |
6 (2.1) |
80 |
|
|
7 |
2018 |
10 |
8 (2.8) |
2 (0.7) |
80 |
|
|
8 |
2019 |
8 |
8 (2.8) |
0 |
100 |
|
|
9 |
2020 |
4 |
4 (1.4) |
0 |
100 |
|
|
10 |
2021 |
1 |
1 (0.3) |
0 |
100 |
|
|
11 |
2022 |
6 |
4 (1.4) |
2 (0.7) |
66.7 |
|
|
12 |
2023 |
9 |
7 (2.4) |
2 (0.7) |
77.8 |
|
|
Total |
290 |
253 (87.2) |
37 (12.8) |
87.2 |
Prevalence of CL, MCL, and VL leishmaniasis
In addition to CL, the pathological characteristics of a few cases resembled MCL and VL. Among 253 positive cases, 97.6% were confirmed CL while 2% positive cases were suspected for MCL and 0.4% for VL (Table II).
Age and gender wise distribution
A total of 70 CL positive and 1 MCL positive case were identified in the age group 21–30, which had the highest frequency of positive cases (24.5%). Followed by age group 31–40 (14.5%) had 41 CL, 1 MCL and age group 11–20 (13.8%) had 38 CL, 1 MCL, and 1 VL positive cases. A single MCL-positive case was identified in the age groups 61–70 and >80, while positive cases in other age groups were identified as CL-positive. The lowest percentage was observed in age groups aged >80 and 0–10 years old, with 2.1% and 2.4%, respectively (Table II, Fig. 3). The statistical analysis revealed a significant association (p<0.05) between positive cases in all age groups.
Table II. Prevalence of cutaneous (CL), mucocutaneous (MCL) and visceral (VL) leishmaniasis by age and gender.
|
Variables |
Total cases |
Positive cases |
Total number of positive cases (%) |
Negative cases (%) |
Prevalence (%) |
Statistical analysis |
||
|
CL |
MCL |
VL |
||||||
|
Age (years) |
||||||||
|
0-10 |
9 |
7 |
0 |
0 |
7 (2.4) |
2 (0.7) |
77.8 |
χ2 = 133.062 d.f = 71 p = 0.00 |
|
11-20 |
46 |
38 |
1 |
1 |
40 (13.8) |
6 (2.1) |
87 |
|
|
21-30 |
79 |
70 |
1 |
0 |
71 (24.5) |
8 (2.8) |
89.9 |
|
|
31-40 |
47 |
41 |
1 |
0 |
42 (14.5) |
5 (1.7) |
89.4 |
|
|
41-50 |
31 |
25 |
0 |
0 |
25 (8.6) |
6 (2.1) |
80.6 |
|
|
51-60 |
28 |
24 |
0 |
0 |
24 (8.3) |
4 (1.4) |
85.7 |
|
|
61-70 |
30 |
26 |
1 |
0 |
27 (9.2) |
3 (1.0) |
90 |
|
|
71-80 |
14 |
11 |
0 |
0 |
11 (3.8) |
3 (1.0) |
78.6 |
|
|
>80 |
6 |
5 |
1 |
0 |
6 (2.1) |
0 |
100 |
|
|
Gender |
||||||||
|
Male |
160 |
137 |
4 |
1 |
142 (48.9) |
18 (6.2) |
88.8 |
χ2 = 3.103 d.f = 1 p = 0.78 |
|
Female |
130 |
110 |
1 |
0 |
111 (38.3) |
19 (6.6) |
85.4 |
|
|
Total |
290 |
247 |
5 |
1 |
253 (87.2) |
37 (12.8) |
87.2 |
|
In gender-wise distribution, the number of positive cases was higher (48.9%) in males compared to females (38.3%). The results revealed that there were 137 CL, 4 MCL, and 1 VL positive cases in males (142/290), while 110 CL and only 1 MCL positive case in females (111/290) were reported (Table II, Fig. 4). The gender-wise distribution was statistically insignificant (p>0.05).
Diagnostic tests
The diagnosis of leishmaniasis cases was confirmed by histopathological testing, which was used in 71.73% cases and the FNAC test in 20.34% cases, and both tests were conducted on 7.93% cases. These tests were performed on reported cases that were suspected of having CL, however, a small number of patients also displayed clinical traits common to VL and MCL (Table III).
Lesion numbers and localization
The majority of the patients (286, 98.62%) had only one number of lesions formed, while 3 patients (1.03%)and one (0.34%) had two and three lesions, respectively (Table III).
Table III. Clinical characteristics of suspected cases of human leishmaniasis.
|
Variables |
Categories |
Number (n) |
Percentage (%) |
|
Lesion localization |
Skin |
124 |
42.75 |
|
Face and head |
84 |
28.97 |
|
|
Hands |
27 |
9.31 |
|
|
Upper limbs |
23 |
7.93 |
|
|
Lower limbs |
24 |
8.28 |
|
|
Other/multiple areas |
8 |
2.76 |
|
|
Number of lesions |
One |
286 |
98.62 |
|
Two |
3 |
1.03 |
|
|
Three |
1 |
0.34 |
|
|
Diagnostic tests |
Histopathology |
208 |
71.73 |
|
FNAC* |
59 |
20.34 |
|
|
Both |
23 |
7.93 |
|
|
Diagnosis/ Pathological findings |
Leishmaniasis (unspecified) |
122 |
42.07 |
|
Cutaneous leishmaniasis |
131 |
45.17 |
|
|
Non-leishmaniasis/others |
37 |
12.76 |
Based on the site of lesion formation, out of 290 suspected cases, the majority had lesions on the skin (42.75%), followed by the face and head areas (28.97%), hands (9.31%), upper limbs (7.93%), lower limbs (8.28%) and 8 (2.8%) lesions were found on other areas of the body (Table III). Mucous areas were also affected, and a few lesions were observed in mouth areas like the mandible, parotid area, salivary gland, and nasal area.
Diagnosis/ pathological findings
The histopathological and FNAC tests verified 253 (87.2%) positive cases. Out of which 122 (42.07%) patients had leishmaniasis (type not specified in clinical reports), 131 (45.17%) had leishmaniasis on the skin, and 37 (12.76%) were not diagnosed with leishmaniasis of any type (Table III). After analyzing unspecified leishmaniasis cases mentioned in clinical reports, we observed that 97.3% cases were CL, 2% were MCL, and 0.4% VL. The clinical features of cases that are not identified show similarities to several kinds of leishmaniasis, according to the World Health Organization report (WHO, 2020).
DISCUSSSION
CL is considered endemic in many regions of Pakistan, including Baluchistan, Punjab, and both CL and VL in Khyber Pakhtunkhwa (KP) (Alvar et al., 2012; Khan et al., 2019, 2021; Hussain et al., 2018). However, CL is the second most prevalent vector-borne disease after malaria in Pakistan (Ejaz et al., 2007). According to our knowledge, not a single epidemiological study has been conducted in Islamabad, Pakistan. Therefore, the current study was designed to investigate and analyze the epidemiology and histopathology of human leishmaniasis in Islamabad, Pakistan. The findings of the current study revealed that 290 suspected cases of human leishmaniasis were reported during the years 2012-2023 of which 87.2% (253/290) were positive and 12.8% were negative. These positive cases included 97.6% CL, 2% MCL, and 0.4% VL.
Preliminary research conducted in Pakistan has shown that CL is more common than other forms of the disease, such as in Baluchistan (Khan et al., 2021), Rawalpindi and Peshawar (Naz et al., 2022), Waziristan (Hussain et al., 2018) and KP (Khan et al., 2016). However, VL is also prevalent in a few areas of KP, Pakistan (Khan et al., 2019). In addition, the studies from Pakistan’s neighboring countries also revealed that CL is prevalent there, including in Iran (Norouzinezhad et al., 2016; Razavi et al., 2021), Afghanistan (Faulde et al., 2008; Fakhar et al., 2017), and India (Sharma et al., 2005; Aara et al., 2013). However, CL is not endemic in China (Lun et al., 2015).
The highest frequency of positive cases was observed in 2013 (17.2%), which decrease gradually until 2021 (0.3%). The years 2019-2021 were periods of COVID-19, and peoples insecurity about visiting hospitals during this outbreak or false diagnosis and masking effect of the coronavirus might be the reasons for this lowest percentage observed (Mouliou et al., 2021). But after the year 2021, a sudden rise has been observed, with 1.4% in the year 2022 reaching 2.4% in the present year 2023. This is an alarming situation because this rise in the infection rate can be a sign of increasing prevalence of CL in Islamabad or overall Pakistan. Moreover, a higher prevalence rate was observed in the month of November of 2012 followed by March of 2013. Similar results had been observed in study from Iran showing infection rate higher in winter-spring season (September to March) (Razavi et al., 2021) but a few other studies had shown inconsistent findings (Khan et al., 2021; Nighat et al., 2022).
In the present study, the infection rate was higher among males than females, which correlates with the other studies from Pakistan (Khan et al., 2016; Sajjjad et al., 2022), and India (Aara et al., 2013). Our findings contradict a study from Muzaffargarh (Nighat et al., 2022), revealed that the infection rate was higher among females compared to males. In our study results, individuals in the age group 21-30 had the highest number of positive cases, followed by 11-20 and 31-40, while adults aged >80 and children 0-10 had the lowest frequency. Similar results have been observed in studies from India (Sharma et al., 2005) and Pakistan including KP (Khattak et al., 2022) and Muzaffargarh (Nighat et al., 2022). But in contrast, a few studies revealed a higher prevalence in children aged 0-15 (Hussain et al., 2018; Sajjjad et al., 2022).
Lesion formation in our study was observed in all 290 cases, and 286 (98.6%) had only one lesion, while the other 4 (1.4%) cases had two or more lesion counts. Correspondingly, a few other studies (Norouzinezhad et al., 2016; Nighat et al., 2022) relate to our findings that the frequency of number the of lesions is mostly one in CL cases. Moreover, in the current study, the site of lesion formation was higher on exposed areas like the skin, face, and head. Similar results were observed in studies from Baluchistan (Khan et al., 2021) and KP (Sajjjad et al., 2022). In contrast, a study conducted in Iran (Razavi et al., 2021) showed the lowest frequency of lesion formation on the face but highest frequency on the hands.
The human leishmaniasis epidemiology is shifting with the emergence of the diseases in different areas of the globe. The most common reasons for changes in the epidemic scenario are migration of human beings and variations in environment due to human activity (Kolaczinski et al., 2004; de Vries and Schallig, 2022). More studies are needed to assess this situation’s severity in Pakistan and take preventive and control measures accordingly to prevent further spread of this scarring disease.
CONCLUSION
The current findings revealed that CL is more prevalent and that the general prevalence of human leishmaniasis is increasing in Islamabad, Pakistan. Nevertheless, our study lacked serological or molecular level evidence of human leishmaniasis, so it is recommended to conduct these studies in Pakistan, particularly in metropolitan cities like Islamabad where travel and migration from endemic areas are anticipated. These studies are required to obtain definite evidence of the burden of human leishmaniasis in Pakistan. Furthermore, increasing public awareness regarding prevention, better diagnostic techniques, and effective treatments can aid in the complete eradication of these life-threatening diseases from Pakistan.
Declarations
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.
Ethical statement and IRB approval
The ethical approval was received from the Ethics Review Board of the Department of Biosciences at COMSATS University Islamabad.
Statement of conflict of interest
The authors have declared no conflict of interests.
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