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Meagan A. Barry Misha V. Koshelev Grace S. Sun Sarah J. Grekin Charles E. Stager A. Hafeez Diwan Carina A. Wasko Kristy O. Murray Laila Woc-Colburn 《The American journal of tropical medicine and hygiene》2014,91(2):345-347
Cutaneous leishmaniasis is rarely seen in the United States. Four Cuban immigrants traveled along the same route at different times from Cuba to Ecuador, then northward, including through the Darién Jungle in Panama. These patients had chronic ulcerative non-healing skin lesions and were given a diagnosis of leishmaniasis.Leishmaniasis is a vector-borne disease caused by the protozoan parasite of the genus Leishmania and is spread by the bite of sand flies from the sub-family Phlebotominae.1 There are various clinical manifestations of leishmaniasis, including cutaneous leishmaniasis (CL), mucocutaneous leishmaniasis, and visceral leishmaniasis. Cutaneous leishmaniasis occurs at the site of the bite, with lesions forming weeks to months later starting with a papule, which then develops into a nodule or plaque-like lesion and progresses to a painless ulceration with an indurated border.We report four cases of CL caused by Leishmania (Viannia) panamensis in Cuban immigrants who traveled through the Darién Gap Jungle between Colombia and Panama on their journey north to the United States. This region has been shown to have high transmission rates of leishmaniasis,2 and, in 2012, Panama experienced an outbreak beyond expected endemic rates.3 This case series highlights a previously underappreciated immigration route to the United States for Cubans and the need to include leishmaniasis as a differential diagnosis for non-healing skin ulcers in this patient population.During May 2012–April 2013, four persons who had recently immigrated to the United States from Cuba came to the National School of Tropical Medicine at Baylor College of Medicine''s (BCM) Tropical Medicine Clinic for non-healing skin ulcers. All four persons reported a similar route of travel from Cuba to Texas (Figure 1), although at different times. Each person began their journey by flying to Quito, Ecuador, where they then traveled by bus through Colombia, passing through the cities of Pasto and Cali to Quibdo. In Quibdo, they took a short flight to Bahia Solano, Colombia, where a boat ride then transported them to Punta Ardita near the Panama border. They then traveled by foot through the thick jungle in Darién, Panama, for 5–15 days. During this time, they slept outdoors and reported numerous insect bites. Once through the Darién area, they traveled northward until they entered the United States at the Mexican border.Open in a separate windowFigure 1.Map showing immigration route of a cluster of Cuban patients with cutaneous leishmaniasis caused by Leishmania (V.) panamensis. Note the travel by foot through the thick jungle of the Darién National Park, Panama, where they likely contracted the disease.Once in the United States, the four persons sought medical care at outside clinics for skin lesions that had developed within two months after they passed though the Darién. They were treated for presumed infection with Staphylococcus aureus. The antibiotics had no therapeutic effect, and the lesions continued to grow and develop into non-healing, painless ulcers with accompanying satellite lesions. Once in Houston, Texas, the four persons were directed to the Department of Dermatology at BCM (Patient Age, years/sex Lesion location; size; presence of satellite lesions (+/−) Diagnosis and pathogen Duration of disease before initiation of treatment Treatment course 1 38/F Proximal right posterior arm; 5 cm; (+) CL L. (V.) panamensis 3 months AmBisome (days 1–5, 14, 21) 2 46/M Distal left forearm; 2 lesions: 4 cm and 3 cm; (+) CL L. (V.) panamensis 2 months AmBisome (days 1–5, 14, 21); then itraconazole (daily, 30 days) 3 43/M Vertex of scalp, 8 more lesions on eyes, legs, and torso; 5 cm, other lesions 1 cm; (+) CL L. (V.) panamensis 2 weeks AmBisome (days 1–5); then pentostam (daily, 20 days) 4 43/F Left malar area; 1.5 cm; (+) CL L. (V.) panamensis 3 months AmBisome (days 1–5, 14)