**6. Differential diagnosis**

**5. Diagnosis**

54 Leishmaniasis - Trends in Epidemiology, Diagnosis and Treatment

not to delay diagnosis [15].

its specificity [2].

It is very hard to detect Leishmaniasis in the initial stage [15]. The long interval between the onset of symptoms and etiological diagnosis of the mucosal form of ATL may reflect the limitation of the training of most physicians in the proper approach to mucosal Leishmaniasis [2]. A laryngoscopy exam usually demonstrates an extensive inflammatory component, with erythema and edemas evident. The granulomatous aspect associated with the presence of ulcers is common, and may present purulent exudate. In the advanced disease, tissue destruc‐ tion can be striking. As a protocol of etiological investigation on suspicion of granulomatous bodies that are difficult to access such as the larynx, laboratory tests and imaging should be requested, and should a diagnostic uncertainty be maintained, a biopsy of the lesions is recommended for histological study. If the appearance of the lesion suggests malignant neoplasm, research using noninvasive and invasive tests should occur simultaneously so as

The ENT examination associated with the Montenegro test remains the most important element for diagnosis, although it is usually of a presumptive character [20]. The encounter of *Leishmania* is the gold standard for the diagnosis of ATL [21]. The diagnosis can be confirmed by various tests: 1) Direct investigation of the parasite, which can be done by scraping the ulcerated surface or by compression of the slide on the wounded area of the lesion. The material is stained with Giemsa or Wright [2]. The direct parasitological examination is the procedure of first choice because it is faster, less expensive and easy to perform [16]. It gives good results in initial lesions, without associated bacterial infection [2], 2) Montenegro intradermoreaction: This translates the response of cell delayed hypersensitivity [16]. It consists of intradermal injection of 0.1 ml of antigen prepared from *Leishmania* promastigotes, with a reading after 48 hours. The test is considered positive that produces an induration of 5 mm or more. However, the positivity of the test indicates that the person has already been sensitized but is not necessarily a carrier of the disease [2]; 3) Histopathological examination of the tegumentary lesion [2]. The Biopsy can be performed with a "punch" of 4 mm in diameter, or a wedge, with the use of a scalpel. In ulcerated lesions, the whole edge of the whole lesion should be preferred, This, in general, shows a tumified and hyperemic aspect [16]; 4) Serology (indirect immuno‐ fluorescence or ELISA); they have good sensitivity but can give a reaction crossed with Chagas disease and visceral Leishmaniasis, this being the cause of false-positive results, thus reducing

The most commonly used techniques for antibodies are: indirect immunofluorescence (IIF), counterimmunoelectrophoresis (CIE ), ELISA and Western blot. The Western blot technique has a superior sensitivity to the other serologic techniques [70.6%), a sensibility of 70.3% and a precision of 72.7%. In the immunocompetents, the specificity and sensitivity are 100% [4]; 5) Immunohistochemical techniques (immunostaining with anti *Leishmania* antibodies); they permit evidence of the parasite in histological sections; 6) Method of culture: culture takes place in Novy-MacNeal-Nicolle medium from the biopsy or aspirate [4]. They are not practical for diagnosis, especially of *Leishmania brasiliensis*, since it does not grow easily in culture media; in addition, bacterial or fungal contamination often complicate this procedure [2]. Research

The finding of symptoms and head and neck moles in patients with Leishmaniasis, paracoc‐ cidioidomycosis and leprosy underscore the need that they all undergo an ENT evaluation. In addition to these diseases, it would be an appropriate conduct to perform complete ENT examination in all patients with some form of granulomatous disease [11]. The differential diagnosis of laryngeal ATL is made with granulomatous lesions such as tuberculosis and paracoccidioidomycosis which have a predilection for the posterior portion of the larynx [2]. The diagnosis of paracoccidioidomycosis is characterized by erosion or exulceration in the oral mucosa, with a granulous base and the presence of stippled hemorrhage (Aguiar Puo's moriform stomatitis), regional lymph node and lung involvement [8]. Syphilitic laryngitis, which fortunately nowadays is rare and appears in the tertiary stage of syphilis may present diffuse infiltrate, which subsequently undergoes ulceration [2]. Tertiary syphilis can be confirmed by histopathological exam, and shows vascular lesions and plasma cell wealth, and VDRL may be positive [8].

Neoplastic lesions of the larynx are more localized and almost always there is a report of smoking and alcoholism in the medical history [2]. Epidermoid and basal cell carcinomas usually present themselves as hardened to palpation, and are confirmed by histopathological examination [8]. Histoplasmosis in its chronic disseminated form involves mucosa in 90%, and the upper airways are affected; the larynx is very adversely affected with infiltration and edema of the laryngeal vestibule, pink nodules on an infiltrated base and granulomatous ulcerations of a granulomatous depth partially covered by yellowish-white secretions that may lead to obstructive dyspnea, requiring a tracheostomy. Generally, in this form of presentation of histoplasmosis there will be alterations in the chest X-ray associated with pulmonary symptoms, which differentiates it from Leishmaniasis. Coccidioidomycosis of the larynx is very rare in our environment. Tracheobronchial amyloidosis with involvement of the larynx is very rare; however, it may present itself with pseudotumoral, bleeding, warty lesions, with a visual appearance similar to the case presented, which can lead to obstruction of the airways [2]. The differential diagnosis is made with rhinophyma, rhinosporidiosis, entomophthoro‐ mycosis, traumatic septal perforation or because of drug use, allergic rhinitis, sinusitis, sarcoidosis, Wegner's granulomatosis and other rarer diseases.

As for lymphomas, histopathological and immunohistochemical exams will help to conclude the diagnosis. In the case of rhinophyma, there is usually a history of rosacea (acne-like lesions and telangiectasias, of long evolution). In the differential diagnosis with rhinosporidiosis what are important are: the origin (Piauí, Maranhão), the history of possible exposure to the fungus in stagnant water and dams, the presence of polyps in the nasal and ocular mucous membranes, and upper respiratory tracts. Histopathological examination shows the microorganism (sporangia of 6 to 300µm). Lesions of entomophthoromycosis present a hardened or woody consistency to palpation and histopathological and mycological exams demonstrate the presence of hyphae and isolation of the fungus in cultur medium. In the differential diagnosis with leprosy, skin sensibility tests, testing of skin bacilli in the lymph of the pinna or lesions and histopathological examination will help confirm the diagnosis. The clinical history is essential when seeking information on personal or family atopy (allergic rhinitis, bronchitis, migraine), on traumatic perforation and use of drugs. Wegner's granulomatosis and sarcoi‐ dosis are rarer diseases, and sometimes difficult to confirm. Diagnosis may be aided by observation of the involvement of other organs such as the lungs and kidneys, it being stressed that the histopathology will contribute to the diagnosis [8].

### **7. Co-infection** *Leishmania* **and HIV**

ATL can modify the progression of the disease due to HIV and immunosuppression caused by this virus facilitating progression of ATL [8]. Acquired immunodeficiency syndrome is caused by a retrovirus of the *Lentiviridae* family, HIV-1 and HIV-2. Those infected with the human immunodeficiency virus (HIV) progress to severe dysfunction of the immune system, as the CD4 + T lymphocytes, one of the major target cells of the virus, are being destroyed [19]. On destroying the immune system, the so-called "opportunistic infections" are manifested as this unfolds in which infections are included, namely infections by protozoa [4]. The assessment of the set of clinical manifestations of ATL in patients with HIV indicates that there is no definition of a clinical profile that may unarguably be associated with co-infection [8]. The exponential increase in the number of cases of coinfection of *Leishmania*/ HIV, especially in the late 1990s, has undergone modifications [4]. Unusual findings can be observed in co-infected patients, suchas, for example, finding *Leishmania spp* in intact skin, and overlying a Kaposi's sarcoma lesion, or *Herpes simplex* and *Herpes zoster* lesions. There may also be involvement of the gastrointestinal tract and the respiratory tract for the coinfection of ATL/AIDS [8]. The population of drug users who inject endovenously is the main group at risk of the co-infection of *Leishmania*/HIV in Southeast Europe, and form 72% of co-infected patients [4].

### **8. Prevention**

Several thorough trials have been carried out on the production of anti- *Leishmania* vaccines: 1) "Leishmanization" has been used empirically since the distant past by people living in endemic areas. This consists of scarification covered with virulent promastigotes of virulent to avoid the appearance of disfiguring lesions in exposed areas. 2) The association of BCG with dead *Leishmania* promastigotes. 3) Vaccines produced by molecular technology from DNA, probably the future of prophylaxis in infectious diseases in immunosuppressed patients [4].
