Treatment of Old World cutaneous leishmaniasis with intralesionally injected meglumine antimoniate using a Dermojet device

Pentavalent antimonial compounds, the mainstay in the treatment of the various forms of leishmaniasis, have considerable toxicity, are difficult to administer and expensive. We describe a safe and efficient therapeutic modality using a spring-loaded and air-powered device for the intralesional injection of a high-velocity meglumine antimoniate microspray in a patient with cutaneous leishmaniasis.     

First case of typical Old World cutaneous leishmaniasis treated with miltefosine

A 26-year-old man presented to our clinic for advice on treatment options regarding cutaneous leishmaniasis (CL) with multiple lesions. The biopsy revealed Leishmania amastigotes; Leishmania major was identified by polymerase chain reaction (PCR).(11 )Leishmania serology (indirect immunofluorescence test) was positive at 1 : 160 (normal, < or = 1 : 40). Ten weeks earlier, the patient had spent a 1-week biking holiday in central Tunisia. Two weeks after returning to Germany, he noticed the flaring up of multiple insect bites (> 40) contracted in Tunisia on both arms. The lesions increased in size and axillary lymph node enlargement occurred. Some of the nodular lesions disappeared spontaneously and some increased in size and showed central ulceration. When we first saw the patient, he had six lesions on his right arm and one on his left arm. The largest lesion was on the dorsum of the right hand (Fig. 1) and showed an indurated edge and central ulceration. Before starting systemic treatment, the patient decided to wait a few weeks in case spontaneous improvement occurred. However, 8 weeks later, the ulceration had further increased in size (Fig. 2) from a diameter of 2 cm initially to a diameter of 5 cm. Regional lymphatic spread with palpable nodules along the adjacent lymphatic vessel had occurred. With the patient's informed consent, treatment with oral miltefosine, according to his body weight of 96 kg, was started at 50 mg three times daily for 28 days. The treatment was well tolerated without any subjective side-effects reported. Liver enzymes, serum creatinine, and urea were monitored during treatment. There was a mild increase in liver enzymes during the third week of treatment: aspartate aminotransferase (AST), 49 U/L (normal, < 35 U/L); alanine aminotransferase (ALT), 107 U/L (normal, < 45 U/L); this resolved spontaneously. Ten days after completion of treatment, the rolled edge had disappeared and the central ulcer had almost healed (Fig. 3). Figure 4 shows the lesion 5 months after completion of treatment.     

Old World eyelid cutaneous leishmaniasis: a case report

Leishmania is a protozoa that may infect the skin, mucous, and viscera. The geographical distribution of cutaneous leishmaniasis (CL) is mainly determined by the sandfly vectors. The Old World type is mainly attributed to Leishmania major and Leishmania tropica, and in South of Europe only to Leishmania infantum. A 63-year-old woman, who noted a pimple on the external third of the left upper eyelid 6 months before. The lesion was nodular, well-defined and measured 1.1 cm in diameter and in height, simulating a basal cell carcinoma. It was surgically excised. CL diagnosis was made upon the histologic examination, which showed histiocytes with intracellular leishmania organisms. At 2 years followup, no evidence exists of cutaneous, mucous, or visceral involvement. Apart from carcinomas, nodular lesions with central ulceration are rare on the eyelid. A single cutaneous lesion of leishmania (oriental sore) has to be considered in the differential diagnosis, along with malignant eyelid neoplasms.     

Efficacy of glucantime in the treatment of Old World cutaneous leishmaniasis

Background  Leishmaniasis is a parasitic disease caused by protozoa of the genus Leishmania. Depending on the parasite species and host response, the disease presents itself in different clinical forms. The cutaneous form of the disease is most common in the Old World. Pentavalent antimonials in the form of an injection represent the most widely used therapy for all clinical forms of the disease. As a result of reports on the development of resistance from various parts of the world, we thought it pertinent to determine its response in our region.
Methods  Two hundred and seven military personnel with cutaneous leishmaniasis, caused by Leishmania major , were treated with glucantime according to the World Health Organization (WHO) recommended protocol. All patients were nonindigenous to the area and had moved from a nonendemic area to a highly endemic area.
Results  Thirty-seven per cent of patients were cured within 15 days. The cure percentage reached 81% when 20 mg/kg/day was continued to 20 days. Twenty-five patients who failed to respond were subjected to a further course of glucantime injection. Sixteen responded by the 10th day of treatment, and the remaining nine were cured by completion of the second course, i.e. within 40 days. The drug was administered intramuscularly. The common side-effects noted were vertigo, headache, anorexia, temperature, and joint pain.
Conclusion  Glucantime is still effective against Old World cutaneous leishmaniasis when used in the doses recommended by WHO.     

Cutaneous leishmaniasis. Treatment with itraconazole

The chemotherapy of leishmaniasis is still far from satisfactory. Itraconazole, one of the most recent azole antifungal agents, appears to be well tolerated in man. Two patients with cutaneous leishmaniasis (Leishmania tropica), contracted in Saudi Arabia, were treated orally for 2 months with itraconazole (100 mg/d). Both recovered without side effects or abnormalities in their main biologic parameters.     

Treatment of imported New World cutaneous leishmaniasis in Germany

Background  Cutaneous leishmaniasis (CL), a parasitic disease which represents a public health problem, particularly in Central and South America, has become a leading condition in travelers who return from tropical countries with skin disorders. Cutaneous leishmaniasis caused by Leishmania (Viannia) braziliensis, the most common causative agent, requires systemic treatment because it is potentially able to disseminate and to cause mucosal or mucocutaneous disease. Although several drugs are available for the systemic treatment of leishmaniases, a definitive treatment regimen for infection caused by species of the Viannia subgenus has yet to be established in many countries, including Germany. Methods  We analyzed treatment outcomes in 23 returnees from Central and South America who were diagnosed with L. (V.) braziliensis CL by polymerase chain reaction. Results  Complete cure within one month following treatment was observed in 18 patients (78%). Cure was achieved with liposomal amphotericin B in 11 of 13 patients, miltefosine in five of eight patients, and meglumine antimoniate in two (of two) patients. Of the five patients (22%) who failed to respond to initial therapy, four were cured with meglumine antimoniate and one with liposomal amphotericin B. Conclusions  In this outcome evaluation of treatment of imported L. (V.) braziliensis infections, liposomal amphotericin B, miltefosine, and meglumine antimoniate proved to be effective. Conventional meglumine antimoniate showed high efficacy as a first‐line treatment and cured lesions that failed to respond to the other two drugs. A multi‐country study using standardized treatment protocols is needed to establish a definitive regimen.     

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.     

特比萘芬口服联合5％咪喹莫特乳膏外用治愈皮肤利什曼病一例

临床资料患者,男,28岁,主因右小腿皮损伴瘙痒6个月,于2012年4月23日就诊。6个月前患者外援到伊拉克,     

Pediatric Old World cutaneous leishmaniasis treated with oral fluconazole: A case series

Background

Cutaneous leishmaniasis has an incidence of 0.7–1.2 million cases per year and represents a growing concern in the outpatient dermatologic practice in Europe because of imported cases due to increased travel to risk areas and to immigration phenomena. When dealing with children, the treatment can be challenging because of side effects and pain of classic antimonial therapy leading to poor rates of course completion and requirement of sedation for several children.

Methods

We retrospectively studied three cases of cutaneous leishmaniasis in pediatric patients, between the ages of 3 and 6 years of age, treated with oral fluconazole. We examined the efficacy, the tolerability, the safety profile and the cosmetic result of fluconazole at a dose of 6 mg/kg/daily for 6 weeks.

Results

The patients had a complete resolution of their lesions with minimal scarring. No adverse effect was reported. The leishmaniasis species identified were L. major or L. tropica .

Conclusion

Considering sides effects and the parents’ and the clinician's concern for systemic treatment in the pediatric population, fluconazole represents a valid, safe and easily manageable option for Old World cutaneous leishmaniasis in pediatric outpatients caused by L. major or L. tropica .