Fig. 46.15. Ultrasonography shows that the enlarged spleen of leishmaniasis is homogeneous. The left kidney is displaced. (Courtesy of Dr. M.W Wachira and WHO: Palmer PES (ed): Manual of Diagnostic Ultrasound, 1995, p129).

Fig. 46.16. Mucocutaneous leishmaniasis destroying the soft tissues around the mouth and nose: there is also secondary infection. In untreated cases, the protozoa may spread to the palate and nasal cartilages.

Fig. 46.17. New World mucocutaneous leishmaniasis. Destruction of the tip of the nose and nasal septum. (From Bittencourt and Barral-Netto 1995).

Fig. 46.18. New World mucocutaneous leishmaniasis. Great enlargement with partial destruction of the nose, conferring a tumoral aspect. There is also ocular involvement on the right side. (From Bittencourt and Barral-Netto 1995).

Imaging Diagnosis

The enlarged spleen of kala azar may grow about 1 inch every month until it fills the abdomen and reaches the pelvis. It may become so large that it is difficult to define the edge both clinically and by imaging. A plain radiograph may show displaced bowel and an overall abdominal haze, which may suggest ascites or merely a fat abdominal wall. Liver enlargement is more variable; it is due to invasion and multiplication of the parasites in the Kupffer cells .and does not parallel the splenomegaly. In some patients the liver may even remain normal in size. Ultrasonography (or CT scanning) will provide the most accurate assessment of splenic and hepatic size (Fig. 46.15).

There are no characteristic findings. The splenic enlargement is nonspecific and similar to that of malaria or any other cause of hypersplenism.

Cutaneous leishmaniasis is known as Oriental, Bush or Pendeh sore, Aleppo, Baghdad or Delhi boil, or, in the Americas, Chiclero ulcer or uto. The International Nomenclature of Diseases (WHO) lists more than 60 synonyms, in addition to the "old" and "new world" varieties. The names are often ancient and conjure up history as well as the geography of the disease. Clinically the skin lesions, particularly in the early stages, can be difficult to recognize and may be mistaken for many other conditions. Unfortunately, this variety of leishmaniasis does not have any specific imaging findings. Only the skin is affected, but in some patients there is reaction in the underlying bone (or cartilage), which almost always indicates a secondary pyogenic (bacterial) infection. In Ethiopia cutaneous leishmaniasis (L. aethiopica) may cause lymphangitis and result in elephantiasis.

Mucocutaneous leishmaniasis (espundia) is due to L. braziliensis and is widely distributed through South and Central America. It particularly affects the nasal cavity, spreading to the pharynx and larynx (Figs. 46.16-46.18). Fungating, eroding ulcers may destroy the nasal cartilages, the soft palate, and fauces, and the tracheal and laryngeal cartilages. The resulting mutilation may be considerable. Bone is not affected unless there is secondary infection. There are no specific radiological findings: the severe mucosal and cartilaginous destruction and secondary infection may give rise to inhalation pneumonia. It may be necessary to image the damaged facial bones, and if reconstructive surgery is eventually considered, CT or MR scanning and three-dimensional reconstruction may be very helpful.