4. Results and Discussion :
Cutaneous leishmaniasis is a worldwide public health and a social problem in many developing countries. Many cases not respond to usual treatment appeared in our country in the last years so the present study was carried out, during the period from November 2017 to April 2018, 122 specimens obtained from patients suspected of cutaneous leishmaniasis admitted to Al-Ramadi Teaching Hospital and dermatology Private clinics, The patients were of different sex, out of 122 specimens, 68 (55.7%) were male while the female gender was 54 (44.3%), the ages were distributed between a year to 68 years where distribution into 7 age groups (1-10 years) 62(50.9%), (11-20 years)29 (23.8%) , (21-30 years)17(13.9%),(31-40 years)8(6.6%) , (41-50 years) 2 (1.6 %) , (51-60 years ) 1(0.8%) and more than 60 years was 3 (2.4%) ,as shown in the (table 4.1),. The total number of specimens that gave positive results of cutaneous leishmaniasis by microscopic examination was 50 (41 %) patients and the number of the specimen that gives negative result was 72(59%). while the specimens that gave positive results by PCR technique for two type of ITS 1 gene and KDNA gene was 62 (51%), 56 (46%) patients respectively and the number of specimens that gave negative results was60 (49%) and 66(54%) patients respectively.
In addition to that , the samples that gave positive result by PCR assay were inserted to nucleic acid two types of restriction enzymes (Hae III and Eae I ) for restricted the ITS1region and KDNA genes of the cutaneous leishmaniasis where Hae III was used for restricted the gene ITS1(350 bp) into (220 bp, 140 bp )for Leishmania major and (200 bp, 60 bp) for Leishmania tropica, KDNA 120bp was failed to digest by Hae III restriction enzyme, even after overnight incubation at 37°C, also the two genes ITS1 350bp and KDNA 120 bp were failed to digest by Eae I restriction enzyme, even after overnight incubation at 37°C. by restriction fragment length polymorphism. There is a statistically significant difference between the rate of infection and the age groups, P0.05, X2=10.23 .
Table (4.2): Distribution of patients according to the age groups based on the microscopic examination results and PCR results.
Age groups Total Microscopic examination PCR
Pos. Neg. Pos. Neg.
1 – 10 62 (50.8) 30(24.6%) 32(26.2%) 35(28.7%) 27(22.1%)
11 – 20 29( 23.8 ) 12(10%) 17(13.8%) 10 (8.2%) 19(15.6%)
21 – 30 17 (14 ) 5(4 %) 12(10%) 9 (7.4 %) 8 (6.6%)
31 – 40 8 (6.6) 2(1.6%) 6(5 %) 5 (4.1 %) 3 (2.5%)
41 – 50 2 (1.6) 1(0.8%) 1(0.8%) 2 (1.6%) 0(0%)
51 – 60 1 (0.8) 0 (0%) 1(0.8%) 1 (0.8%) 0(0%)
61 – 70 3 (2.4) 0 (0%) 3(2.4%) 0 ( 0 %) 3 (2.4%)
Total No. 122 (100) 50(41%) 72(59%) 62(50.8%) 60(49.2%)
P >0.05 X2=5.99 x2=10.23
This result is agreement with other Iraqi studies as (164,165,166) in Al-Qadisiya governorate. Also (167) observed in another study higher infection appeared in age group 10years and less. also similar results were obtained by (168) who found cases were recorded from lowland provinces with moderate annual rainfalls and a high rural population and same age range, present result agree with that in neighbouring countries as in Syria (13), in Jordan, (169) decided that age group (2-19) years was also more susceptible to the infection by CL than another age group. Iran ( 170,171) and Turkey (172).
whereas (41) obtained the highest infections of CL in the age group (5-14yr.), While the lowest infection of CL was observed in the age group (>1yr.). also (173) who confirmed that majority of cases were recorded among age groups 15–45 years old. Also (174) who documented More frequency of the infection in the age group of (19-32) years while the lowest infection rate was noticed among age groups between (5-18) years. (150,175) also found that the high incidence of infection occurs in older than 15 years. Another study by (176) and (177) also established the lowest frequency among the age group older than 50 years. The reason for the low rate of elderly patients may be related to the fact that they were infected during their early ages and acquired long-term immunity during childhood ,another factor is that older people do not admit to the treatment of CL while they know this disease and disfiguring scars are not as important for them as for youngsters (178).
Also, this differences could be due to this age playing outdoors for a long time and more exposure to the infected sand flies; many investigators postulated that the decrease in incidence with age was due to development of immunity by previous infections (40).
The result of present and other studies pointed to, this diseases can infect the individuals at any age. Also, the (5) reported that people of all ages are at risk for infection if they live or travel where Leishmania spp is found.
4.2. Gender :
The distribution of cutaneous leishmaniasis infection between males and females by using microscopic examination was indicated in table (4.3), The patients were of different sex, out of 122 specimens, 30(24.6%) were males while the rate of infection between females were 20(16.4%), the differences between the gender and the infection rate with cutaneous leishmaniasis were no statistically significant by using microscopic examination (p>0.05), (x2=0.626).
Table(4.3): Distribution of patients according to the gender based on the microscopic examination and PCR results.
Gender Total Microscopic examination PCR
Pos. Neg. Pos. Neg.
Male 68(55.7%) 30(24.6%) 38(31.1%) 37(30.3%) 31(25.4%)
Female 54(44.3%) 20(16.4%) 34(27.9%) 25(20.5%) 29(23.8%)
Total 122(100%) 50(41%) 72(59%) 62(50.8%) 60(49.2%)
Depending on genders, The present study revealed the rate of cutaneous leishmaniasis which is higher in males than in females by using microscopic examination and PCR assay. In Iraq (40) also found that males were (57%) and females were (31.7%). Another study by (176) recorded that the infection in males was 65% than females (35%). (179) also decided that the prevalence in males higher than females. Similar results were also established in studies by (41), (177). In Saudi Arabia, (180) documented that the incidence rate of CL was higher in males than in females in Al Hassa from 2000 to 2010. In Syria, (181) found that Syrian males are more infected with the parasite than females, In Jordan, (169) and in Iran (182) and (183) were also recorded that the prevalence rate was most frequently in males than females. The same result in Turkey (184), This is probably happened due to the cultural habits of most areas.
Otherwise, the results of the present work appeared to disagree with the other previous Iraqi studies by (167) and (185). Also (150) found in his epidemiological study of Cutaneous Leishmaniasis in Tuz found females are more infection than males, in Yemen by (186) who documented that females most infected with CL than males.
These results may be attributed to the fact that males are more exposed to the insect biting more than females due to working outdoors and also due to men are less covering than women then exposed (175). Although it is believed that sex hormones may influence the establishment and the course of parasitic diseases, behavioural factors, making male individuals more likely to be exposed to vectors in fields and other transmission environments, are probably equally or more important(179).
The males are more exposed to the environment where the sand flies present by walking near rivers or swimming beside males work in the farms, while the females mostly staying in the houses ( 187). (188) found the highest per cent of infection related to the geographical site which was near water stream flow all year and abundance of fresh water holes which provide sand flies a suitable environment to complete its life cycle and increase agriculture activities.
4.3. Residency :
The distribution of cutaneous leishmaniasis in rural and urban areas by using microscopic examination was referred in the table (4.4), the rate of infection with cutaneous leishmaniasis in urban area was 5(4.1%) while in rural area was 45(36.9%) The rate of infection in rural area was higher than the urban area with no statistically significant difference between the rural and urban areas by using microscopic examination. (x2=1.523),(p>0.05).
Table (4.4): The rate of infection with cutaneous leishmaniasis according to residency based on microscopic examination and PCR.
Residency Total Microscopic examination PCR
Pos. Neg. Pos. Neg.
Urban area 18(14.7%) 5(4.1%) 13(10.6%) 8 (6.5%) 10(8.2%)
Rural area 104(85.3%) 45(36.9%) 59(48.4%) 54(44.3%) 50(41%)
Total 122(100%) 50(41%) 72(59%) 62(50.8%) 60(49.2%)
P>0.05 X2=1.523 X2=0.343
While the rate of infection with leishmaniasis by using PCR assay, this technique appeared the prevalence of cutaneous leishmaniasis in rural areas was 54(44.3%) while in urban areas was 8(6.5%), with no statistically significant difference between the rural and urban areas by using PCR assay.(P>0.05),(X2=0.343).
The distribution of cutaneous leishmaniasis in a rural area was higher than the urban area, this result is agreement with other Iraqi studies as (40),( 175), (179) and (189) in Al-Qadisiya governorate. Also (167) and (190), in Libya (191), in Syria (12), in Jordan, (169), in Iran (171), and in Turkey (172). However, a different result had been recorded by (165, 192, 193, 194, 195).
Leishmaniasis usually is more common in rural than in urban areas because there are many factors that play an important role in the presence and distribution of CL in this district, including the presence of animal reservoirs such as rodents, dogs, etcetera; the presence of marshes; and the use of clay to build some of the houses in villages that belong to this district area. Furthermore, as an agricultural area, attracts and harbours many kinds of insects; therefore, its population works long hours in the farms where they
are more exposed to insects bites (40). but it is found in the outskirts of some cities. ( 184). (196) reported that the people who may have an increased risk for infection (especially with the cutaneous form) include adventure travellers, ecotourists, Peace Corps volunteers, missionaries, soldiers, ornithologists (people who study birds), and other people who do research (or are active) outdoors at night and the transmission risk is highest from dusk to dawn because this is when sand flies generally are very active also the duration of infection depending on Immunity of people, place of infection, number of lesions and have treatment.
4.4. Body site of infection :
Different parts of the patient’s body were observed with infection of Baghdad boil including face, arms, legs and feet, but number of patients infected in arms (upper limbs) had the highest percentage (48%) when compared to other sites of infection, followed by legs and feet (28.6%), , face (20.8%) and other site (shoulder ,thorax and neck) (2.6%) ,with highly significant differences (P