Case of Cutaneous Leishmaniasis reported in NEJM

Dr Alexia P. Knapp and Dr Jonathan D. Alpern at HealthPartners Institute, St. Paul, MN have reported a rare case of Cutaneous Leishmaniasis. The case has appeared in the New England Journal of Medicine.

Leishmaniasis is caused by the protozoan Leishmania parasites which are transmitted by the bite of infected female phlebotomine sandflies. There are 3 main forms of the disease: visceral (also known as kala-azar and the most serious form of the disease), cutaneous (the most common), and mucocutaneous. Cutaneous leishmaniasis (CL) is not life-threatening but it can have disfiguring lesions and devastating effects on local communities. Early diagnosis and treatment are essential to reduce the reservoir of infection and control cutaneous leishmaniasis.

A 19-year-old man presented to the dermatology clinic with a 3-month history of an enlarging ulcer on the dorsal aspect of the right hand and multiple tender subcutaneous nodules on the right forearm and elbow. Five months earlier, the patient had travelled to Ecuador, where he had worked at an organic produce farm. On physical examination, the ulcer measured 3 cm in diameter and was found to be tender with a firm border (Panel A).

A punch-biopsy specimen of the edge of the ulcer showed a dense infiltrate of lymphocytes and histiocytes containing intracellular organisms consistent with leishmania amastigotes (Panel B). A polymerase-chain-reaction assay of the specimen was performed, and the species was identified as Leishmania panamensis. Treatment with oral miltefosine (at a dose of 50 mg three times daily for 28 days) was initiated. Cutaneous leishmaniasis caused by L. panamensis can disseminate to the oro nasopharyngeal mucosa. A fiberoptic examination of the nasopharynx performed 6 days after the patient began treatment showed no evidence of mucosal disease. Ten days after the completion of therapy, the ulcer had healed with an atrophic scar, and the number and size of the subcutaneous nodules were markedly reduced.