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