Cutaneous leishmaniasis in travellers and migrants: a 10-year case series in a Canadian reference centre for tropical diseases

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Figure 1:
Locations of the main (i.e., most prominent) lesion for each patient (n = 48). We did not identify any significant differences in location between patients with cutaneous leishmaniasis who were exposed in the Old World (Mediterranean basin, Middle East, Central Asia) or the New World (Americas) (p = 0.24).
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Figure 2:
Clinical photographs of cutaneous leishmaniasis. A) A solitary ulcer with raised erythematous borders, caused by an infection of Leishmania (Viannia) braziliensis acquired in French Guinea. B) An ulcer with thick violaceous and raised borders, caused by an infection of L. tropica cutaneous leishmaniasis acquired in Pakistan. C) A large, crusted ulcer with satellites papules, caused by an infection of L. (Viannia) panamensis acquired in Colombia. All photographs from Sapha Barkati, McGill University Health Centre, Montréal, Que.

Table 1:

Demographic and clinical characteristics of 48 returned travellers and migrants with cutaneous leishmaniasis, 2008–2018

Characteristic	No. (%) of patients^*			p value
Characteristic	Total n = 48	Old World exposure n = 15	New World exposure n = 33	p value
Gender				0.3
Male	28 (58)	7 (47)	21 (64)
Female	20 (42)	8 (53)	12 (36)
Age, yr, median (IQR)	43.5 (24.5–58.5)	53 (31.5–62)	36 (24–54)	0.2
Traveller type				0.6
Returned traveller	43 (90)	14 (93)	29 (88)
Migrant	5 (10)	1 (7)	4 (12)
Immune status				0.6
Immunocompetent	46 (96)	14 (93)	32 (97)
Immunocompromised	2 (4)	1 (7)^§	1 (3)^¶
Region of exposure				–
North or Central America	24 (50)	–	24 (73)
South America	9 (19)	–	9 (27)
North Africa	5 (10)	5 (33)	–
Sub-Saharan Africa	3 (6)	3 (20)	–
Middle East	5 (10)	5 (33)	–
South or Central Asia	1 (2)	1(7)	–
East Asia	1 (2)	1(7)	–
Purpose of travel (among returned travellers, n = 43)				0.02
Tourism	24 (56)	5 (33)	19 (58)
Visiting friends and relatives	7 (16)	6 (40)	1 (3)
Work or business	5 (12)	2 (13)	3 (9)
Education or research	2 (5)	0 (0)	2 (6)
Volunteer or aid worker	5 (12)	1 (7)	4 (12)
Duration of travel (among returned travellers, n = 43), d, median (IQR)	42 (21–90)	60 (23–94)	36 (27–75)	0.5
Time from initiation of symptoms to diagnosis, d, median (IQR)	89 (58–134)	98.5 (90–146)	84 (57–127)	0.2
No. of physicians consulted before visit to reference centre, median (range)^†	2 (0–5)	2 (1–5)	2 (0–3)	0.3
No. of course of systemic or topical antibiotics before visit to reference centre, median (range)^‡	1 (0–4)	1 (0–3)	1 (0–4)	0.4

Note: IQR = interquartile range.
↵* Unless indicated otherwise.
↵† Data missing for 2 patients.
↵‡ Data missing for 1 patient.
↵§ Patient with systemic lupus erythematosus on low-dose prednisone and hydroxychloroquine.
↵¶ Patient with HIV with CD4 count at low end of normal range.

Table 2:

Clinical characteristics of the lesions from cutaneous leishmaniasis

Table 4:

First- and second-line treatments used to treat cutaneous leishmaniasis

Treatment	No. (%) of patients who received first-line treatment			No. (%) of patients who received second-line treatment

	Total n = 47	Old World exposure n = 15	New World exposure n = 32	Total n = 16	Old World exposure n = 8	New World exposure n = 8
Local	2 (4)	2 (13)	0 (0)	4 (25)	3 (38)	1 (12)

Systemic	36 (77)	12 (80)	24 (75)	9 (56)	3 (38)	6 (75)

No treatment	9 (19)	1 (7)	8 (25)	3 (19)	2 (25)	1 (12)

Specific treatment^*	38 (81)	14 (93)	24 (75)	13 (81)	6 (75)	7 (88)

Liposomal amphotericin B	20 (53)	4 (29)	16 (67)	4 (31)	1 (17)	3 (43)

Oral fluconazole	10 (26)	5 (36)	5 (21)	3 (23)	1 (17)	2 (29)

IV pentavalent antimonial	4 (11)	3 (21)	1 (4)	2 (15)	1 (17)	1 (14)

Topical paromomycin	1 (2.5)	1 (7)	0 (0)	2 (15)	1 (17)	1 (14)

Pentamidine	1 (2.5)	0 (0)	1 (4)	0 (0)	0 (0)	0 (0)

Topical paromomycin with fluconazole	1 (2.5)	0 (0)	1 (4)	0 (0)	0 (0)	0 (0)

IL pentavalent antimonial	1 (2.5)	1 (7)	0 (0)	1 (8)	1 (17)	0 (0)

Cryotherapy	0 (0)	0 (0)	0 (0)	1 (8)	1 (17)	0 (0)

Note: IL = intralesional, IV = intravenous.
↵* Percent frequencies are a proportion of all patients who received a specific treatment.