New World Cutaneous Leishmaniasis Treated with Intralesional Injection of Pentavalent Antimony

Cutaneous leishmaniasis is a skin infection caused by the Leishmania species, an intracellular protozoan parasite that is transmitted by various species of female sandflies. According to the geographic distribution and vectors, leishmaniasis is classified as Old World or New World cutaneous leishmaniasis. In Korea, 24 cases of Old World cutaneous leishmaniasis have been reported, but New World cutaneous leishmaniasis has not been reported as yet. A 37-year-old man presented with a 3-month history of a painful and erythematous nodule with two satellite papules on the left postauricular area and a papule on the left arm after traveling to the Amazon region in Brazil. After we performed skin biopsies of the lesions, diagnosis of cutaneous leishmaniasis was made by the histopathological findings. After intralesional injection of sodium stibogluconate (Pentostam®, GlaxoSmithKline) twice a week for 4 weeks, the lesions improved with scarring. Herein, we discuss this case of New World cutaneous leishmaniasis that was successfully treated with intralesional injection of sodium stibogluconate (Pentostam®) in Korea.     

Erysipeloid leishmaniasis: an unusual clinical presentation.

Old World cutaneous leishmaniasis has many different clinical presentations. A rare and unusual presentation of cutaneous leishmaniasis is the erysipeloid type. This clinical form is not only unusual in its clinical features but also in the specific category of patients it seems to afflict. In this report 5 Iranian patients, predominantly females, between 50 and 70 years of age, presented with infiltrative erythematous lesions covering the center of the face and resembling erysipelas. Skin smears and/or skin biopsies revealed the diagnosis of cutaneous leishmaniasis. The reason for this type of presentation is unclear, although factors such as the specific species involved, the host's immune response, the hormonal changes encountered with increasing age, and the changes in skin barrier with ageing can be speculated as being important points in causing such an unusual presentation.     

Clinical spectrum of cutaneous leishmaniasis: an overview from Pakistan

The clinical spectrum of leishmaniasis encompasses subclinical (inapparent), localized (skin lesions), and disseminated infection (cutaneous, mucosal, or visceral). The clinico-pathological picture of cutaneous leishmaniasis is variable and depends not only on the leishmania species but also on endemic region, host factors, and immuno-inflammatory responses. Symptomatic disease is subacute or chronic and diverse in presentation and outcome. Pakistan is one of the countries in which cutaneous leishmaniasis is becoming an epidemic disease and because of its morbidity and disfiguring scars, it is considered a serious public health problem. This is an attempt to review the clinical spectrum of old world cutaneous leishmaniasis, classical and unusual clinical presentations, occurring in Pakistan.     

Cutaneous sporotrichoid leishmaniasis resistant to pentavalent antimonial therapy: complete resolution with itraconazole

Sporotrichoid leishmaniasis is a sporadic form of cutaneous leishmaniasis, a protozoal infection, reported particularly in the Middle East. Clinically it occurs as nontender, subcutaneous, slightly erythematous nodules, often associated with lymphangitis, usually on exposed areas of the skin. Sometimes it occurs after treatment with a single dose of antimonials, and in older lesions, the biopsy can be negative for amastigotes. We report a case of cutaneous sporotrichoid leishmaniasis unresponsive to intralesional pentavalent antimonial therapy, which completely resolved after treatment with oral itraconazole. To our knowledge, this is only the third such case reported. We discuss the causes of dissemination of the nodular lesions and the negative results for amastigotes on re‐biopsed lesions.     

Cutaneous silica granuloma in a child

A 12-year-old girl had a 4-year history of two asymptomatic, sharply demarcated, granulomatous lesions on her face. The lesions did not respond to topical steroids and histopathologic examination of biopsy specimens showed granulomatous inflammation. Since cutaneous leishmaniasis is endemic where the patient lived, she was diagnosed as chronic cutaneous leishmaniasis but did not respond to meglumine antimoniate treatment. Reexamination of the biopsy specimens under polarized light revealed numerous birefringent crystalline particles, and cutaneous silica granuloma was the final diagnosis. The lesions were treated with intralesional triamcinolone acetonide and completely disappeared. We report this case of cutaneous silica granuloma, which is unusual in children, and emphasize the importance of polarized light microscopic examination of granulomatous skin diseases.     

Cutaneous leishmaniasis as travelers' disease. Clinical presentation, diagnostics and therapy

Leishmaniasis is a disease with worldwide increasing incidence, which in Germany is almost exclusively observed in patients who have travelled to classical endemic regions such as the Mediterranean basin. Cause of the disease is an infection with protozoan parasites of the genus Leishmania, which are transmitted by sand flies and replicate intracellularly within mammalian hosts. Depending on the inoculated parasite (sub-) species and the immune status of the host, a local cutaneous, diffuse cutaneous, mucocutaneous or visceral form of leishmaniasis will develop. Cutaneous leishmaniasis, which frequently appears only weeks after the bite of a sand fly, starts with the formation of a papule, which subsequently can turn into a skin ulcer. The latter may heal spontaneously after months leaving behind a scar or persist as chronic, non-healing cutaneous leishmaniasis. If cutaneous leishmaniasis is suspected, a sterile skin biopsy followed by appropriate diagnostic measures in a specialized laboratory to identify the pathogen should be performed. For the decision on the type of therapy, several clinical parameters (e.g. number and localization of lesions, immune status) and, most importantly, the underlying parasite (sub-) species need to be considered. Therapy can consist of a variety of topical measures or systemic drug treatment. A modern and safe vaccine does not yet exist.     

Cutaneous and mucocutaneous leishmaniasis

Leishmaniasis is a cluster of diseases caused by protozoa in the genus Leishmania . There are three basic clinical forms: cutaneous, mucocutaneous, and visceral leishmaniasis. The present review focuses on the diagnosis and treatment of cutaneous and mucocutaneous leishmaniasis. Characteristics of both the human host and the parasite species influence the clinical disease manifestations that range from asymptomatic exposure, to self-healing skin ulcers, to life-threatening widespread destructive ulcerations. Whether through medical treatment or through spontaneous resolution, skin ulcerations generally result in disfiguring scars with significant social and economic impact. Tests to confirm the diagnosis should be performed on patients who have recently visited endemic areas and have skin or mucosal manifestations consistent with leishmaniasis. Treatment depends on the species of Leishmania and the risk of widespread or disfiguring disease. Because of increasing trends in global travel, educating health care providers to recognize and treat leishmaniasis in both endemic and non-endemic countries is imperative.     

Relapse of cutaneous leishmaniasis in a patient with an infected subcutaneous rheumatoid nodule

Cutaneous leishmaniasis is a protozoal infection generally considered to be limited to the skin. In Israel, the disease is common in geographically defined areas and is caused predominantly by Leishmania major. Sporotrichoid subcutaneous spread has been reported but is uncommon. We describe a patient with rheumatoid arthritis, treated with methotrexate and prednisone, in whom numerous rheumatoid nodules concomitant with cutaneous leishmaniasis were found, mimicking sporotrichoid spread of the disease. In a rheumatoid nodule that was examined by electron microscopy, Leishmania parasites were found at intracellular and extracellular locations. This observation supports the hypothesis that cutaneous leishmaniasis parasites persist after clinical cure of the disease and may re-emerge as a result of immunosuppression.     

Immunofluorescence in cutaneous leishmaniasis

A case of acute cutaneous leishmaniasis is reported in which skin biopsy of the lesion revealed deposits of IgM, fibrinogen and C3 in the blood vessel wall and granular deposits of IgG and C3 at the dermoepidermal junction. No immune complexes were detected in the healthy unaffected skin in the same patient and no circulating immune complexes were found in the blood. This case demonstrates tissue-bound immune complexes in cutaneous leishmaniasis.     

Disseminated cutaneous leishmaniasis secondary to lymphoedema: two cases

BACKGROUND: Dissemination of cutaneous leishmaniasis may take various forms: satellite papules, sporotrichoid nodules and widespread papulonodular lesions (disseminated cutaneous leishmaniasis). We describe a particular clinical form of dissemination in two patients with erysipelas secondary to lymphoedema. PATIENTS AND METHODS: Case 1. A 75-year-old man with diabetes consulted for erysipelas of the leg secondary to lymphoedema. The site of entry was an infected cutaneous leishmaniasis lesion. The initial outcome was favourable under intravenous penicillin G treatment. Twelve days later, some fifty papulonodular lesions appeared and were strictly limited to the erythematous erysipelas plaque. PCR screening of papulonodular lesion smears for Leishman bodies was positive. Histological examination of skin biopsy samples showed lobular panniculitis. Case 2. A 64-year-old woman with diabetes presented erysipelas in the right upper limb secondary to lymphoedema scattered with multiple erythematous, infiltrated, papular lesions in a setting of cutaneous leishmaniasis lesions. PCR analysis of smears taken from the secondary nodular lesions demonstrated the presence of leishmaniasis, while histological analysis of biopsy samples revealed panniculitis. DISCUSSION: Disseminated cutaneous leishmaniasis is characterized by the appearance of multiple (>10) pleomorphic lesions on two or more noncontiguous areas of the body. Our two patients presented certain features of disseminated cutaneous leishmaniasis. However, they were unusual in terms of the strict localisation of nodular lesions to the erysipelas plaque. This particular aspect suggests haemolymphatic dissemination of the protozoan infection from the initial lesion as a result of local factors.     

Dissemination in cutaneous leishmaniasis due to Leishmania major in different ethnic groups in Saudi Arabia

BACKGROUND: Dissemination in patients with cutaneous leishmaniasis has previously been recorded in human infection with Leishmania major and L. tropica. In this study, the potential for dissemination in different ethnic groups in Saudi Arabia was compared. METHODS: The data were recorded from a group of 73 patients with suspected cutaneous leishmaniasis (43 Saudi and 30 non-Saudi) attending the Dermatology Clinics at King Fahd Hospital of the University and Al-Khobar Government Hospital at Al-Khobar, Eastern Region of Saudi Arabia. The patients were of various age groups (all male) between 1 and 55 years. The diagnosis of cutaneous leishmaniasis was confirmed clinically and by smear and skin biopsy. The following data were recorded for each patient: type, number, and anatomic sites of disseminative lesions and the frequency of co-occurrence of more than one type of lesion. RESULTS: Three types of disseminative lesions due to zoonotic cutaneous leishmaniasis were recorded in 16 patients (21.92%): subcutaneous nodules, satellite papules, and subcutaneous induration. The percentage of disseminative lesions in non-Saudi patients (36.66%) was higher than in Saudi patients (11. 63%). This was also true for the number of lesions: a mean of 12.27+/- 10 and 6.4+/-3, respectively. The coexistence of more than one type of disseminative lesion was higher in non-Saudi patients (63. 63%) than in Saudi patients (20.0%), as well as the occurrence of lesions on more than one body site: 36.4% in non-Saudi patients and 20.0% in Saudi patients. CONCLUSIONS: The potential for dissemination due to cutaneous leishmaniasis was significantly higher in the nonindigenous population than in the indigenous population in Saudi Arabia. Disseminative lesions must be clinically differentiated from other skin diseases and appropriately treated by avoiding the use of intralesional drugs or physical therapy.     

Cutaneous leishmaniasis mimicking inflammatory and neoplastic processes: a clinical, histopathological and molecular study of 57 cases

Background: Cutaneous leishmaniasis displays considerable variation in its histopathological and clinical presentation. Clinically, it progresses from a papule into a painless ulcerated and crusted nodule/papule. Microscopically, it progresses from sheets of amastigote‐filled histiocytes to granulomatous inflammation. Methods: The study was conducted on 145 skin biopsies from untreated patients with histopathological and/or clinical suspicion of cutaneous leishmaniasis in Lebanon, Syria and Saudi Arabia (1992–2010). The pre‐biopsy clinical diagnosis and demographic data were collected. Biopsies were evaluated for the major microscopic pattern, and the parasitic index (PI) was also determined. Diagnosis was confirmed by polymerase chain reaction (PCR) followed by molecular sub‐speciation. Results: Of the 145 patients, 125 were confirmed as cutaneous leishmaniasis by PCR. Eighteen cases presented with a pre‐biopsy clinical diagnosis other than cutaneous leishmaniasis that ranged from dermatitis to neoplasm. Of the 125 cases, 57 showed a major histopathological pattern other than cutaneous leishmaniasis. Identification of amastigotes was equivocal (PI ≤1) in 38 of the 57 cases. Of interest, all the 18 cases with a pre‐biopsy clinical diagnosis other than cutaneous leishmaniasis also showed atypical histopathology for cutaneous leishmaniasis. Conclusions: The manifestations of cutaneous leishmaniasis are broad and may mimic other inflammatory and neoplastic diseases. Pathologists and dermatologists should be aware of such pitfalls and can utilize PCR to confirm the diagnosis of leishmaniasis. Saab J, Fedda F, Khattab R, Yahya L, Loya A, Satti M, A‐G Kibbi, Houreih MA, Raslan W, El‐Sabban M, Khalifeh I. Cutaneous leishmaniasis mimicking inflammatory and neoplastic processes: a clinical, histopathological and molecular study of 57 cases.     

New world leishmaniasis. Serologic aids to diagnosis.

The increase in travel to endemic areas of South and Central America has led to an increase in the number of cases of cutaneous leishmaniasis diagnosed in the United States. Traditional methods of diagnosis for this disease include microscopical examination of infected tissue, culture of Leishmania on special media, and the leishmanin skin test. The present communication describes a case of cutaneous leishmaniasis and the difficulties that were encountered in diagnosis. New methods of serologic testing allow more prompt and accurate diagnosis.     

Transient effect of topical treatment of cutaneous leishmaniasis with imiquimod

BACKGROUND: Treatment of cutaneous leishmaniasis can be painful and protracted and cosmetic results are often unsatisfying. The immune modulator imiquimod has been reported to be suitable for the treatment of a variety of infectious skin diseases and neoplasias. OBJECTIVE: We investigated the efficacy of topical application of imiquimod in the treatment of old world leishmaniasis in a placebo-controlled prospective study. METHODS: Twelve patients were treated with imiquimod cream using a standard protocol, i.e. topical application three times a week, and a further three served as control group. RESULTS: Lesions of cutaneous leishmaniasis regressed within the first 2-4 weeks in 10 of the 12 patients, whereas in two patients no change was observed. However, after 8 weeks all lesions showed progression. CONCLUSION: Our results thus demonstrate that topical application of imiquimod alone is ineffective in treating old world cutaneous leishmaniasis. Further studies are required to demonstrate a possible benefit of imiquimod in combination with other, preferably orally administered medicines.     

Can a simple outpatient‐based treatment be used to treat cutaneous leishmaniasis in young children? A Critically Appraised Topic

A 5‐year‐old boy from rural Afghanistan presented with a 1‐year history of a skin lesion on his left knee, confirmed by polymerase chain reaction to be cutaneous leishmaniasis (Leishmania tropica). Conventional treatment of cutaneous leishmaniasis involves intravenous or intralesional pentavalent antimonials. The aim of this Critically Appraised Topic (CAT) is therefore to determine what alternative effective but less painful treatments (such as oral or topical therapies) can be used to treat cutaneous leishmaniasis in children. Embase and PubMed were searched for ‘cutaneous leishmania*’ AND ‘treatment’ AND ‘children’ in August 2014. All abstracts from April 2008 to August 2014 were reviewed. This search period was chosen to follow on from the Cochrane reviews on Old World and American leishmaniasis. Five randomized controlled trials met our inclusion criteria and have been included in this CAT. The study design and reporting quality in most of the trials included in both Cochrane reviews was found to be poor, and neither Cochrane review investigated the effect of patient age on response to treatment. This CAT identified two nonpainful treatments, topical paromomycin and oral miltefosine, whose effective use in children is supported in the literature. However, both of these treatments are currently unlicensed in the U.K. Our patient was successfully treated with miltefosine 20 mg twice daily for 4 weeks, leading to good resolution of the leishmaniasis plaque but with residual scarring.     

American cutaneous leishmaniasis unresponsive to antimonial drugs: successful treatment using combination of N-methilglucamine antimoniate plus pentoxifylline

BACKGROUND: American cutaneous leishmaniasis is characterized by single or multiple ulcerations. Cytokines, among other factors, have been shown to influence lesion development and tumoral necrosis factor-alpha is a major cytokine implicated in pathogenesis of ulcers. OBSERVATIONS: We tested oral pentoxifylline, a known tumoral necrosis factor-alpha inhibitor, at doses of 400 mg (2-3x/day), associated to N-methylglucamine antimoniate (15 mg/kg/day) in two patients with American cutaneous leishmaniasis unresponsive to antimonial drugs. We observed a satisfactory response with quick cure of skin lesions of these patients. CONCLUSIONS: Our results suggest that oral pentoxifylline in association to N-methylglucamine antimoniate should be consider in refractory cutaneous leishmaniasis patients.     

Comparison of tuberculosis cutis luposa and cutaneous leishmaniasis

We present a comparative study concerning two cases of tuberculosis cutis luposa and cutaneous leishmaniasis, respectively. These two Turkish female patients had suffered from changes of the facial skin since 20 years (tuberculosis cutis luposa) and for 5 months (cutaneous leishmaniasis). The tuberculosis cutis luposa had been misdiagnosed as cutaneous leishmaniasis and surgically treated. Both cases showed an apple jelly-like color at the edges of the lesions with soft tissue. With tuberculosis cutis luposa, the lesions had a larger extension and a more hyperkeratotic picture. We discuss the different histopathologic changes of both cases. As bacteriologic culture revealed mycobacterium tuberculosis, on one hand, and histopathology leishmania species intrahistiocytically, on the other, we could finally make the corresponding diagnoses.     

Cutaneous leishmaniasis in a Japanese returnee from West Africa successfully treated with liposomal amphotericin B

Leishmaniasis has been occasionally reported in returnees from endemic areas. Here, we report a case of cutaneous leishmaniasis in a 33-year-old Japanese man who presented with a skin nodule after returning from an 8-year stay in West Africa including Burkina Faso. He was successfully treated with liposomal amphotericin B with no significant adverse effects. This is the first Japanese case of cutaneous leishmaniasis treated successfully with liposomal amphotericin B.     

Disseminated mucocutaneous leishmaniasis resulting from chronic use of corticosteroid

Mucocutaneous leishmaniasis is a granulomatous disease clinically characterized by ulcerated skin and mucosal lesions whose clinical manifestations can regress spontaneously, but with possible long subclinical evolution. The course of the disease is often related to the host immune response. The purpose of this article is to describe the clinical and microscopic findings of cutaneous and mucosal lesions of mucocutaneous leishmaniasis in a patient who presented an unusual form of the disease associated with an immunosuppressive state.     

Cutaneous leishmaniasis in Mali

While not as common as in other parts of the world, cutaneous leishmaniasis is endemic to countries in Africa, particularly in the north, central, east, and south. Sporadic case reports of cutaneous leishmaniasis in countries spanning West Africa have allowed scientists to propose an endemic belt in sub-Saharan Africa ranging from Senegal to Cameroon. While the presence of cutaneous leishmaniasis in West Africa is well established, there is a paucity of data regarding the parasite species, vector, and reservoir responsible for the disease in this part of the continent. This article focuses on cutaneous leishmaniasis in Mali, West Africa.