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Cutaneous Leishmaniasis -- Ohio

On January 19, 1985, a 23-year-old male graduate student in Ohio noted an ulceration on his left middle finger. He had visited the jungle of the San Blas Islands, Panama, 1 month earlier, where he was bitten by many insects. The ulcer became larger despite administration of oral erythromycin and dicloxacillin. On February 20, the student was admitted to a regional hospital with a 2x2-cm indurated ulcer overlying the proximal interphalangeal joint. There was no evidence of lymphatic spread. A biopsy from the edge of the lesion showed an intense lymphohistiocytic infiltrate involving the entire dermis. Cultures for bacteria, fungi, and mycobacteria were negative. He was treated with intravenous nafcillin and discharged on oral tetracycline.

The lesion persisted, and on March 14, another biopsy was performed. The same histologic picture was seen, and all cultures were again negative. A serum specimen submitted to CDC in March for Leishmania antibody testing had a titer of 1:16 by complement fixation (CF) and of 1:16 by indirect immunofluorescent antibody (IFA). By March 21, the ulceration had expanded, with subcutaneous nodules on the back of the hand extending up the arm. Epitrochlear and axillary adenopathy were present. A third biopsy was performed and submitted to Walter Reed Army Hospital for Leishmania culture. Growth of Leishmania braziliensis was reported on April 8.

The patient was treated with 10 mg/kg/day sodium stibogluconate intravenously for 21 days. At the beginning of the treatment, the ulceration measured 4.8 cm x 3.5 cm; by the end, the size of the ulcer had decreased 75% and was granulating well, and the subcutaneous nodules on the dorsum of the arm had resolved. Three months after completion of therapy, the ulcer had completely healed with only minimal adenopathy remaining. Reported by C Camisa, MD, J Plouffe, MD, A Parks, MD, Dept of Medicine, Ohio State University, Columbus, B Green, MD, Dept of Medicine, Case Western University, Bowling Green, Ohio; Protozoal Diseases Br, Div of Parasitic Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: An estimated 12 million cases of leishmaniasis, visceral and cutaneous, occur worldwide each year (1). The protozoa, transmitted by the Phlebotomus sp., sandfly, occurs focally in the Americas from Yucatan, Mexico, through Central and South America to the Peruvian Andes. Old World cutaneous leishmaniasis is similarly widespread from the Union of Soviet Socialist Republics through the Middle East and Africa. The geographic distribution of the various Leishmania species was recently tabulated by the World Health Organization (2). Autochthonous human cutaneous leishmaniasis has been rarely seen in the United States and appears limited to south central Texas (3). The principal vectors and animal reservoir hosts in Texas have not been clearly defined.

The diagnosis is made via needle aspirate or tissue biopsy of the indurated margin of the ulcer. Giemsa stain should reveal 2-3 um amastigotes, which appear pale blue with a red kinetoplast. However, in this case, Giemsa stain and other histologic preparations were unrewarding, and culture was necessary. Culture should be done on appropriate media (NNN or Schneider's Drosophila), and can be arranged with CDC ((404) 452-4240) through state and local health departments. Serology has superseded skin testing for Leishmania infection, since antigen for skin testing is no longer available in the United States. The serologic tests currently used at CDC are the CF and IFA, with a titer greater than 1:8 considered positive for CF and 1:16 for IFA. Cross-positive reactions are seen with Trypanosoma cruzi. A low or absent titer for cutaneous leishmaniasis does not rule out infection, as antibody may not be produced.

Three species of cutaneous Leishmania are seen in the Americas. Ulcers caused by L. peruviana or L. mexicana may heal spontaneously; however, those of L. braziliensis should always be treated because of the frequent occurrence of metastatic lesions. Treatment with antimonial compounds (in the United States, sodium stibogluconate, available through CDC: telephone (404) 329-3670) is generally successful, but relapses have been reported.

The present case reminds U.S. clinicians that leishmaniasis should be included in the differential diagnosis of cutaneous ulcers in travelers, foreign visitors, and immigrants from endemic areas. Multiple diagnostic modalities, histology, culture, and serology may be needed to confirm infection; perseverance and consideration of the appropriate diagnoses were responsible for the successful treatment of this patient.

References

  1. Walsh JA, Warren KS. Selective primary health care: An interim strategy for disease control in developing countries. N Engl J Med 1979;301:967-74.

  2. World Health Organization. The Leishmaniases: Report of a WHO expert committee. Geneva, 1984. WHO technical report series no. 701.

  3. Gustafson TL, Reed CM, McGreevy PB, Pappas MG, Fox JC, Lawyer PG. Human cutaneous leishmaniasis acquired in Texas. Am J Trop Med Hyg 1985;34:58-63.

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