CORRECT DIAGNOSIS:
Cutaneous Leishmaniasis
DISCUSSION:
The evaluation of skin lesions in patients with recent travel history can be challenging. In addition to considering vector-borne diseases with known associations with areas of travel, one must also consider non-infectious and non-travel related etiologies. A case of a 51-year-old male who recently visited Colombia is presented. During his travels, he developed a non-pruritic papule on the forearm which, over the course of weeks, progressed into a persistent ulcerative lesion. A biopsy was performed and histopathologic findings were consistent with leishmaniasis. The differential diagnosis of ulcerative lesions in travelers will be discussed. In the evaluation of lesions in travelers returning to the United States, prompt recognition and early diagnosis may play important roles in outcomes.
Leishmaniasis is a vector-borne illness with an annual worldwide incidence of approximately 2 million. It is caused by infection with a parasite from the Leishmania genus of the Family Trypanosomatidae. This genus includes over 20 species of obligate intracellular flagellated protozoa. Transmission of the parasite is via the bite of infected female sandflies of the genus Phlebotomus (Old World) or Lutzomyia (New World). While the disease can be found worldwide, it is endemic in South America and the Mediterranean basin. Most cases diagnosed in the United States are in troops returning from the Middle East or in travelers returning from endemic areas. Texas is the only state known to have primary cases of the illness. Reservoirs include rodents, dogs, foxes, sloths, and sometimes humans. The 4 main clinical patterns of leishmaniasis include: cutaneous, mucocutaneous, diffuse cutaneous, and visceral. While the cutaneous form is the most common, the other forms have also been found in the region visited by our patient.
The lesion of New World cutaneous leishmaniasis is often solitary. A painless papule on an exposed area is the most common initial presentation. This may first appear several weeks after inoculation. Over time the papule may develop into a plaque or nodule which may ulcerate and have a violaceous border.4 This painless lesion can reach several centimeters in size. Spontaneous resolution with scarring often occurs over several months. A minority of cases, however, will become chronic or disseminated.
TREATMENT:
The patient was sent for a consultation with Infectious Disease. He was started on oral therapy with fluconazole, as well as, topical paromomycin. Courses of fluconazole 200mg daily for 6 weeks have been shown to be efficacious in the treatment of leishmaniasis.
REFERENCES:
Freedman, D. O., Weld, L. H., Kozarsky, P. E., Fisk, T., Robins, R., von Sonnenburg, F., Keystone, J. S., Pandey, P., Cetron, M. S., & GeoSentinel Surveillance Network. (2006). Spectrum of disease and relation to place of exposure among ill returned travelers. New England Journal of Medicine, 354(2), 119. https://doi.org/10.1056/NEJMoa051204
PMID: 16467525
Lederman, E. R., Weld, L. H., Elyazar, I. R., et al. (2008). Dermatologic conditions of the ill returned traveler: An analysis from the GeoSentinel Surveillance Network. International Journal of Infectious Diseases, 12, 593. https://doi.org/10.1016/j.ijid.2007.12.013
PMID: 18406266
Ryan, E. T., Wilson, M. E., & Kain, K. C. (2002). Illness after international travel. New England Journal of Medicine, 347, 505-516. https://doi.org/10.1056/NEJMra012865
PMID: 12140389
Lucchina, L. C., Wilson, M. E., & Drake, L. A. (2008). Dermatology and the recently returned traveler: Infectious diseases with dermatologic manifestations. International Journal of Dermatology, 36(3). https://doi.org/10.1111/j.1365-4632.2008.03684.x
Bolognia, J., Jorizzo, J., & Schaffer, J. (Eds.). (2012). Dermatology (3rd ed.). Elsevier.
Alrajhi, A. A., Ibrahim, E. A., De Vol, E. B., Khairat, M., Faris, R. M., & Maguire, J. H. (2002). New England Journal of Medicine, 346, 891-895. https://doi.org/10.1056/NEJMoa013553
PMID: 11952704
