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cutaneous leishmaniasis (oriental sore)

Etiology: 1) Old World cutaneous leishmaniasis: - Leishmania tropica - Leishmania major - Leishmania aethiopica - Leishmania donovani & Leishmania infantum may also cause cutaneous lesions 2) New World cutaneous leishmaniasis: - Leishmania mexicana - Leishmania braziliensis - Leishmania amazonensis - Leishmania venezuelensis - Leishmania garnhami - Leishmania pifanoi - Leishmania peruviana - Leishmania panamensis - Leishmania guyanensis Epidemiology: 1) transmitted to humans by at least 30 species or subspecies of sandfly 2) Old World cutaneous leishmaniasis: - occurs in southern Europe, northern & eastern Africa, the Middle East, Iran, Afghanistan, India, southern Russia 3) New World cutaneous leishmaniasis: - tropical & subtropical New World - southern Texas in USA - dogs are reservoirs of L. peruviana - wild animals are reservoirs for most species of Leishmania Pathology: 1) infection produces long-lasting immunity 2) lymphatic spread & local lymphadenopathy are common 3) scarring Microscopic pathology: - dense infiltrate of lymphocytes & histiocytes containing intracellular organisms consistent with leishmania amastigotes * image [5] Clinical manifestations: 1) General - begins as an erythematous papule at the site of sandfly bite - enlarges to nodules or plaques & ulcerates over 2 weeks to 6 months - a dusky, violaceous hue may develop, & central crusting can overlie an ulcer - typical presentation is a single lesion, but smaller surrounding papules &/or numerous, widespread lesions may be present - local lymphadenopathy is common - lesion usually resolves spontaneously in a few months, resulting in a lifelong scar 2) Old World cutaneous leishmaniasis: - ulcers develop on an exposed area of the skin & heal spontaneously - L. tropica produces urban or dry ulcer that persists longer than the rural or wet ulcer due to L. major - L. aethiopica causes a more severe cutaneous infection which may produce mucosal lesions or diffuse cutaneous 3) New World cutaneous leishmaniasis: - leishmaniasis resembling leprosy - lesions involving L. mexicana involve the earlobe (chiclero ulcer), are self-limiting & do not involve mucosa - L. mexicana & L. amazonensis may produce diffuse cutaneous lesions similar to those produced by L. aethiopica * image [5] Laboratory: 1) biopsy border of most active lesion 2) make imprints 3) smear prepared from tissue cut from surface at border or lesion 4) Giemsa staining 5) Leishmania DNA, Leishmania rRNA Management: 1) meglumine antimoniate may be treatment of choice [4] - unclear whether FDA-approved for use in U.S. 2) sodium stibogluconate a) available from CDC (404 639-3670) b) 20 mg Sb[V]/kg IM/IV for 20-28 days c) intralesional injections is alternative [3] 3) pentamidine 3 mg/kg IM QOD for 4 doses 4) ketoconazole 600 mg PO QD for 28 days 5) itraconazole 200 mg PO BID for 28 days 6) miltefosine (Impavido) 50 mg TID for 28 days [5]

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References

  1. Clinical Diagnosis & Management by Laboratory Methods, 19th edition, J.B. Henry (ed), W.B. Saunders Co., Philadelphia, PA. 1996, pg 1266-68
  2. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 1192
  3. Reithinger R et al. Cutaneous leishmaniasis. Lancet Infect Dis 2007 Sep; 7:581. (review) PMID: 17714672
  4. Chaabane H, Turki H Cutaneous Leishmaniasis with a Paronychia-like Lesion. N Engl J Med 2014; 371:1736. October 30, 2014 PMID: 25354107 http://www.nejm.org/doi/full/10.1056/NEJMicm1314869
  5. Knapp AP, Alpern JD Images in Clinical Medicine. Cutaneous Leishmaniasis. N Engl J Med 2020; 382:e2. Jan 9 PMID: 31914245 https://www.nejm.org/doi/full/10.1056/NEJMicm1908092