Cutaneous Leishmaniasis

Synonyms: Oriental sore, Delhi boil, Baghdad boil, Balkan sore, Saldana

Incubation period: a couple of weeks to a couple of months depending on the species

Epidemiology:

Source: http://www.who.int/leishmaniasis/leishmaniasis_maps/en/index.html

Leishmaniasis threatens 350 million people in 88 countries where the disease is endemic. With 12 million cases worldwide, over 1.5 million people report new cases of cutaneous leishmaniasis annually, while many more go unreported. 90% of these cases occur in Saudi Arabia, Afghanistan, Peru, Brazil and Iran. From 2002-2004, 522 new cases of cutaneous leishmaniasis, mostly due to L. major, were reported among troops stationed in Afghanistan, Iraq, and Kuwait.

Pathogenesis:

When an individual is bitten by the sandfly, promastigotes are introduced into the skin and enter small blood vessels and macrophages around the affected area. There, the parasites proflierate as amastigotes. White blood cells, called lymphocytes, then attack the immediate area using white blood cells called lymphocytes and the amastigotes are liberated from the macrophages. A lump then forms and breaks open when the blood flow to the area is compromised. Although the ulcer may become infected, the lesion usually heals as the body builds immunity against the parasite. Once an individual is infected with cutaneous leishmaniasis, it is unlikely that he or she will be re-infected by the same species.

Clinical Manifestations:

Photo courtesy of (L-R): http://www3.baylor.edu/~Charles_Kemp/hand.jpg, http://www.ualberta.ca/~medlabsc/leishmaniasis.jpg , http://www.who.int/zoonoses/diseases/Leishmaniasis2_ok.jpg, http://www.yamagiku.co.jp/pathology/image/176/8.jpg

The ulcers may change in size and may appear differently throughout the course of infection. Although most sores may be painless, some may cause extreme disability. The sores can heal spontaneously within a few months, however, they may also leave permanent scars. Recovery depends on the host's immune system. If the sores are not treated appropriately, they can last for many years.

Diagnosis:

Treatment:

Drug

Mechanism of action

Dosing

Therapy Duration

Side effects

Results

Sodium Stibogluconate (Pentostam)

*Not licensed for use in the US

Cause parasite death by inhibiting glycolytic enzymes and fatty acid oxidation

Administered intravenously or intra-muscularly

20 mg/kg body weight daily for 20 days

Coughing, headache, vomiting

Cutaneous lesions may not usually require antimonials to heal. After several weeks, the lesions tend to heal on their own.

Glucantime

*Not licensed for use in the US

Cause parasite death by inhibiting glycolytic enzymes and fatty acid oxidation

Administered intravenously or intra-muscularly

20 mg/kg body weight daily for 20 days

EKG ab-

normalities

Cutaneous lesions may not usually require antimonials to heal. After several weeks, the lesions tend to heal on their own.

Amphotericin B

*preferred treatment in India and Mediterranean because of poor response to antimonials

Causes parasite death

intravenously

Gradually increase dose to 1mg/kg lb every other day until 2-3g is given

Slightly toxic

Cutaneous lesions may not usually require antimonials to heal. After several weeks, the lesions tend to heal on their own.

Oral ketoconazole

Alters permeability of cell wall inhibiting fungal enzymes

Oral, topical

Oral: 200-400 mg/day single daily dose, 4-8 wks

Topical: rub on affected area 1-2x daily

Headache, vomiting, abdominal pain

Itraconazole

Inhibits cell membrane formation

Oral, intravenously

200 mg, once daily and may increase to 400 mg from 1 day-6 months depending on severity

Gastric acidity

Paromomycin

 

Interferes with bacteria protein synthesis

oral

25-35 mg, 3 divided doses, 5-10 days

Diarrhea, nausea, eosinophilia

Flucanazole

*Antifungal

Inhibits cell membrane formation

oral

200-400 mg/day, duration depends on infection

Complete healing of all lesions

Photos (top-bottom): http://www.usp.org/patientSafety/newsletters/practitionerReportingNews/prn1202004-09-30.html?USP_Print , http://arachosia.univ-lille2.fr/labos/parasito/Internat/medicam/leish_me.html , http://medimpex.com.mx/generic/antimycotics-c-35.html?osCsid=e16e52b335ecd493c77e6140a16d2564

Home

Sources:

http://www.who.int/leishmaniasis/disease_epidemiology/en/index.html

http://www.afip.org/Departments/infectious/lm/01.html

http://www.utdol.com/utd/content/topic.do?topicKey=parasite/16332

Markell and Voges. “Leishmaniasis.” Medical Parasitology . Elsevier Inc. Ninth Edition. 2006.