Experience with New World cutaneous leishmaniasis in travelers

doi:10.1067/S0190-9622(03)01576-7

Journal of the American Academy of Dermatology

Volume 49, Issue 4, October 2003, Pages 672-678

https://doi.org/10.1067/S0190-9622(03)01576-7 Get rights and content

Abstract

In recent years, New World cutaneous leishmaniasis has been seen at a higher incidence among returning Israeli travelers. Leishmania braziliensis and related species cause unsightly cutaneous lesions possibly complicated with a mucosal disease. A total of 12 patients with New World cutaneous leishmaniasis were treated in our clinic, 11 of whom (92%) acquired the disease in the Bolivian Amazon Basin. Five (42%) had regional lymphadenopathy in addition to cutaneous lesions. Polymerase chain reaction was performed for 8 patients to identify the causative Leishmania species. In all, 9 patients (75%) were cured by a single course, and 3 (25%) after an additional course of intravenous sodium stibogluconate. The treatment was well tolerated clinically. Laboratory abnormalities, mainly elevation of liver enzymes (58%), were reversible. We concluded that polymerase chain reaction is a useful tool in establishing the species diagnosis of leishmaniasis and that sodium stibogluconate appears to be a safe and effective treatment for L braziliensis infection.

Section snippets

Patient population

The patients described herein were travelers referred to the dermatology clinic or to the Center for Geographic Medicine at Sheba Medical Center, Tel Aviv, Israel. New World cutaneous leishmaniasis was defined as (1) presence of cutaneous lesions (ulcers, nodules, papules) compatible with leishmaniasis; (2) history of recent travel to the Americas (New World); and (3) biopsy specimen or smear showing Leishmania amastigotes within the dermal infiltrate.

Polymerase chain reaction

PCR was performed for cases that occurred

Results

Between the years 1998 and 2001, 12 patients with New World cutaneous leishmaniasis were examined in the study. The clinical and epidemiologic data of patients are shown in Table II. Mean age was 25 years (range: 23-29); incubation period was 1.7 months (range: 1-3); the patients had a mean of 2.5 cutaneous lesions with mean lesion size of 2.5 cm (range: 0.5-6); and distribution of the lesions was 40% on the upper aspect of limbs, 32% on the lower aspect of limbs, 12% on the head and neck, and

Discussion

Travel to developing countries has become more common in recent years, increasing physicians' encounter with imported tropical diseases.9 In the past 4 years, 12 patients presented at our clinic with imported L viannia braziliensis infection. In 11 of the patients (92%), infection was attributed to travel to the Amazon Basin in Bolivia. Although the tropical Amazonian region of Bolivia is known to be endemic to L viannia braziliensis,10, 11 it has never been mentioned as a high-risk area for

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Cited by (47)

Axillary hidrosadenitis due to Leishmania: Case report and literature review
2016, Cirugia y Cirujanos
La hidrosadenitis es la abscesificación tras la infección de las glándulas sudoríparas apocrinas. Se localiza frecuentemente en: axila, ingle, periné, región perineal y cuero cabelludo.
Varón de 37 años de edad, sin antecedentes personales de interés. Acudió al servicio de Cirugía General derivado por su médico de Atención Primaria por hidrosadenitis axilar de años de evolución. En la exploración física presentaba signos de hidrosadenitis en ambas axilas, con una marcada hidrosadenitis supurativa en la axila derecha. Se procedió a la extirpación en bloque de la zona afectada con resultado anatomopatológico de leishmaniasis cutánea. Posteriormente, se le administró ácido fusídico de forma tópica con infiltraciones de un mililitro Glucantime^®.
La hidrosadenitis supurativa afecta a zonas intertriginosas y se presenta con nódulos inflamatorios subcutáneos recurrentes. La incidencia en el sexo femenino es 3 veces superior al masculino.
La hidrosadenitis aislada por Leishmania es poco frecuente, aparece en zonas endémicas y en pacientes inmunodeprimidos, como con VIH.
La clínica puede ser muy diversa. Histopatológicamente, se puede confirmar el diagnóstico con hematoxilina-eosina. El patrón predominante presenta un granuloma desorganizado y sin necrosis.
El tratamiento puede ser sistémico o local. Actualmente, destacan las inmunoterapias.
La hidrosadenitis causada por Leishmania en paciente VIH negativo es una patología muy rara. De ahí la importancia de un buen diagnóstico histológico y tratamiento adecuado.
Hidradenitis is a disorder where abscesses appear after the infection of the apocrine sweat glands. It is located normally in the axillae, groin, perineal region, and the scalp.
A 37 year old male was referred by his GP to the General Surgery Department with axillary hidradenitis which had evolved over the years. The physical examination shows signs of hidradenitis in both axillae, with a noticeable suppurative hidradenitis in the right armpit. En bloc extirpation was performed to remove the whole affected area. The pathological examination revealed a cutaneous leishmaniasis. Subsequently, fucidin was administered topically, as well as local infiltrations of one millilitre of Glucantime™.
Hidradenitis normally appears in intertriginous areas and its manifestation is accompanied by recurrent subcutaneous nodules. The incidence rate in females is three times higher than in males.
The isolated Hidradenitis caused by Leishmania is a rare condition presented only in endemic areas or in immunocompromised patients, such as HIV-infected patients.
Clinical manifestations can be different and the diagnosis can be confirmed through haematoxylin-eosin. The main pattern displays a disorganised granuloma without necrosis.
Systemic or topical treatment can be applied. Immunotherapy treatment is the most common.
Hidradenitis caused by Leishmania in HIV-negative patients is a rare condition. Therefore it is important to perform a good histological diagnosis and to administer the right treatment.
Leishmaniasis in travelers: A literature review
2014, Travel Medicine and Infectious Disease
Leishmaniasis is a vector-borne protozoan infection whose clinical spectrum ranges from asymptomatic infection to fatal visceral leishmaniasis. Over the last decades, an increase in imported leishmaniasis cases in developed, non-endemic countries, have been pointed-out from a review of the international literature. Among the possible causes are increasing international tourism, influx of immigrants from endemic regions and military operations. The main area for the acquisition of cutaneous leishmaniasis, especially for adventure travelers on long-term trips in highly-endemic forested areas, is represented from South America, whereas popular Mediterranean destinations are emerging as the main areas to acquire visceral variant. Leishmaniasis should be considered in the diagnostic assessment of patients presenting with a compatible clinical syndrome and a history of travel to an endemic area, even if this occurred several months or years before. Adventure travelers, researchers, military personnel, and other groups of travelers likely to be exposed to sand flies in endemic areas, should receive counseling regarding leishmaniasis and appropriate protective measures.
Not to be missed! Differential diagnoses of common dermatological problems in returning travellers
2013, Travel Medicine and Infectious Disease
After systemic febrile illnesses and diarrhoea, dermatological disorders are the third most frequent health problem of returning travellers consulting travel clinics. While most travel-related dermatological problems are mild, self-limiting and rather harmless, the challenge is to pick up on dermatological clues to potentially severe or even life-threatening diseases. This article provides an overview of the most common and the ‘not to be missed’ dermatological diagnoses in international travellers.
Liposomal amphotericin B in comparison to sodium stibogluconate for Leishmania braziliensis cutaneous leishmaniasis in travelers
2013, Journal of the American Academy of Dermatology
Citation Excerpt :
This lengthy treatment course is associated with significant adverse events.4,5 In addition, our past experience has been that this course proved effective in achieving clinical cure in only 71% to 77% of cases.3,6,7 The role of liposomal amphotericin B (L-AmB) in the treatment of New World CL has not been studied systematically with different regimens (5-10 days) and follow-up periods ranging from 1 to 36 months.8-13
New World cutaneous leishmaniasis is mostly acquired in the Amazon Basin of Bolivia where L viannia (V) braziliensis is endemic. Treatment with systemic pentavalent antimonial compounds has been shown to be effective in achieving clinical cure in only 75% of cases.
We sought to assess the efficacy and safety of liposomal amphotericin B (L-AmB) treatment for primary infection of cutaneous L (V) braziliensis.
A prospective observational evaluation was performed for cutaneous leishmaniasis due to L (V) braziliensis which was treated with L-AmB, 3 mg/kg, for 5 consecutive days, and a sixth dose on day 10. This therapy regimen was compared with the treatment regimen of sodium stibogluconate (SSG) 20 mg/kg for 3 weeks.
Our study was divided into two groups; 34 patients received L-AmB and 34 received SSG treatment. Almost all patients were infected in Bolivia. In the L-AmB group, 29 patients (85%) had complete cure compared with 70% in the SSG group (P = not significant), 4 other patients were slow healers, and only one patient needed additional treatment with SSG. No relapses were seen during a mean 29-month follow-up period. Failure rate was 3% in the L-AmB versus 29% in the SSG group (P = .006). Treatment was interrupted in 65% of patients taking SSG because of adverse events, whereas all patients receiving L-AmB completed treatment.
This was a non-blinded comparative study.
Comparison of L-Amb to SSG treatment for L (V) braziliensis shows that the former is effective, better tolerated, and more cost effective. L-AmB should therefore be considered as the first-line treatment option for cutaneous L (V) braziliensis infection.
Local or systemic treatment for New World cutaneous leishmaniasis? Re-evaluating the evidence for the risk of mucosal leishmaniasis
2012, International Health
This review addresses the question of whether the risk of developing mucosal leishmaniasis (ML) warrants systemic treatment in all patients with New World cutaneous leishmaniasis (CL) or whether local treatment might be an acceptable alternative. The risk of patients with New World CL developing ML after the initial infection has been the main argument for systemic treatment. However, this statement needs re-evaluation and consideration of all the available data. The putative benefit of preventing ML should outweigh the toxicity of systemic antileishmanial therapy. To assess the need for and risk of systemic treatment the following factors were reviewed: the incidence and prevalence of ML in endemic populations and in travellers; the severity of mucosal lesions; the efficacy of current options to treat ML; the toxicity and, to a lesser extent, the costs of systemic treatment; the risk of developing ML after local treatment; and the strengths and limitations of current estimates of the risk of developing ML in different situations. Local treatment might be considered as a valuable treatment option for travellers suffering from New World CL, provided that there are no risk factors for developing ML such as multiple lesions, big lesions (>4 cm²), localisation of the lesion on the head or neck, immunosuppression or acquisition of infection in the high Andean countries, notably Bolivia.
Systematic review of the adverse effects of cutaneous leishmaniasis treatment in the New World
2011, Acta Tropica
Pentavalent antimonials are first-line drugs for the treatment of the cutaneous form of American tegumentary leishmaniasis. Second-line drugs include amphotericin B and pentamidine. Although these drugs have been used for decades, there are no systematic reviews about their safety. The objective of this review was to identify and classify the main adverse effects associated with these drugs and to estimate the frequency of these effects, whenever possible. Intervention studies, case series and case reports containing information regarding clinical, laboratory or electrocardiographic adverse effects of drugs used for the treatment of cutaneous leishmaniasis were systematically retrieved from 10 databases searched between August 13, 2008 and March 31, 2009. The 65 studies included in this review had treated a total of 4359 patients from 12 countries infected with eight different Leishmania species. Despite the small number of drugs used in these studies, a wide variability in the therapeutic regimens was observed. As a consequence, the adverse effects of pentavalent antimonials and pentamidine needed to be classified jointly according to system, irrespective of formulation, daily dose, duration of treatment, and route of administration. The frequencies of adverse effects were calculated based on the data of 32 articles involving 1866 patients. The most frequently reported clinical adverse effects of pentavalent antimonials and pentamidine were musculoskeletal pain, gastrointestinal disturbances, and mild to moderate headache. Electrocardiographic QTc interval prolongation and a mild to moderate increase in liver and pancreatic enzymes were additional adverse effects of pentavalent antimonials. Patients treated with liposomal amphotericin B had mild dyspnea and erythema. The adverse effects associated with miltefosine were vomiting, nausea, kinetosis, headache, diarrhea, and a mild to moderate increase in aminotransferases and creatinine. Although closer surveillance is needed for the treatment of cutaneous leishmaniasis, antileishmanial drugs are basically safe and severe side effects requiring the discontinuation of treatment are relatively uncommon.

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Deutsche Forschungsgemeinsschaft enabled the laboratory work by funding research on the epidemiology of leishmaniasis.

Conflicts of interest: None identified.

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Journal of the American Academy of Dermatology

Abstract

Section snippets

Patient population

Polymerase chain reaction

Results

Discussion

References (20)

Diseases of the mononuclear phagocytic system

Leishmaniasis

Lancet

Amplification of kinetoplast DNA as a tool in the detection and diagnosis of Leishmania

Exp Parasitol

Detection of cutaneous Leishmania infection in paraffin embedded skin biopsies using the polymerase chain reaction

Trans R Soc Trop Med Hyg

Simplified polymerase chain reaction detection of New World Leishmania in clinical specimens of cutaneous leishmaniasis

Am J Trop Med Hyg

Diagnosis of Leishmania using the polymerase chain reactiona simplified procedure for field work

Am J Trop Med Hyg

Health woes grow in shrinking world

JAMA

Cited by (47)

Axillary hidrosadenitis due to Leishmania: Case report and literature review

Leishmaniasis in travelers: A literature review

Not to be missed! Differential diagnoses of common dermatological problems in returning travellers

Liposomal amphotericin B in comparison to sodium stibogluconate for Leishmania braziliensis cutaneous leishmaniasis in travelers

Local or systemic treatment for New World cutaneous leishmaniasis? Re-evaluating the evidence for the risk of mucosal leishmaniasis

Systematic review of the adverse effects of cutaneous leishmaniasis treatment in the New World

ReportExperience with New World cutaneous leishmaniasis in travelers☆

Abstract

Section snippets

Patient population

Polymerase chain reaction

Results

Discussion

Diseases of the mononuclear phagocytic system

Leishmaniasis

Lancet

Amplification of kinetoplast DNA as a tool in the detection and diagnosis of Leishmania

Exp Parasitol

Detection of cutaneous Leishmania infection in paraffin embedded skin biopsies using the polymerase chain reaction

Trans R Soc Trop Med Hyg

Simplified polymerase chain reaction detection of New World Leishmania in clinical specimens of cutaneous leishmaniasis

Am J Trop Med Hyg

Diagnosis of Leishmania using the polymerase chain reactiona simplified procedure for field work

Am J Trop Med Hyg

Health woes grow in shrinking world

JAMA

Report
Experience with New World cutaneous leishmaniasis in travelers☆