Old World Cutaneous Leishmaniasis

Pictures of old world cutaneous leishmaniasis and disease information have been excerpted from the VisualDx® clinical decision support system as a public health service. Additional information, including symptoms, diagnostic pearls, differential diagnosis, best tests, and management pearls, is available in VisualDx.

Full Clinical Write-up

Synopsis

Old World cutaneous leishmaniasis (OWCL) is endemic in the Mediterranean basin, Africa (particularly in North and East Africa, with sporadic cases elsewhere), the Middle East, Central Asia, the Indian subcontinent, and China.

Cutaneous leishmaniasis results from infection of the skin with obligate intracellular parasites of the Leishmania genus. The parasites are transmitted by the bite of infected female phlebotomine sandflies (species in the Lutzomyia genus in the New World and in the Phlebotomus genus in the Old World). The World Health Organization (WHO) estimates that 1.5 million new cases of cutaneous leishmaniasis occur each year, and leishmaniasis is on the WHO’s list of neglected tropical diseases. Children are more frequently affected due to increased exposure to sandflies and underdeveloped immune systems. Over 90% of the cases occur in the following countries:

Old World
Afghanistan, Algeria, Iran, Iraq, Pakistan, Saudi Arabia, and Syria

New World
Brazil and Peru

OWCL is most commonly caused by infection with Leishmania major and Leishmania tropica. Other species causing OWCL include Leishmania aethiopica, Leishmania infantum, and Leishmania donovani. In the Old World, female sandflies in the genus Phlebotomus carry Leishmania species. The reservoir hosts for the zoonotic Leishmania species include dogs, rodents, opossums, gerbils, hyraxes, and others. Infected humans are the reservoir hosts for L tropica, which is anthroponotic and often endemic in urban areas. Recent periods of civil unrest and armed conflicts, with resultant poor sanitation and vector control, are some of the factors associated with ongoing epidemics of OWCL in Afghanistan and Iraq.

Typically, the primary lesion starts as erythema at the site of a sandfly bite. Thereafter, it evolves, over weeks to months, from a papule to a nodule, which may then ulcerate with an elevated violaceous rim. Lymphangitis that ascends the lymphatic chain (sporotrichoid spread) and lymphadenopathy (sometimes bubonic) can be seen; the latter may precede the presence of skin lesions. Pruritus, pain, and bacterial superinfection may also be present. Systemic symptoms are rarely seen.

Multiple primary lesions on one part of the body may be seen; this can result from the probing behavior of sandflies as they attempt to get blood meals. Multiple lesions are more commonly noted in patients infected with L major than L tropica; up to 20 ulcers can be seen simultaneously in L major infection and fewer than 3 from L tropica. Ultimately, over months to years, lesions may heal without therapy, leaving hypopigmented, atrophic scars.

Chronic relapsing cutaneous leishmaniasis (leishmania recidivans) represents reactivation of infection. It is most commonly caused by L tropica and typically manifests as papules at the margins of scars, occurring months to years after clinical resolution of the initial ulcer.

Diffuse cutaneous leishmaniasis (DCL) is a rare variant caused by L aethiopica. It occurs in the context of leishmanial-specific anergy and is manifested by disseminated, nonulcerated lesions.

Look For

A smooth, erythematous, nonhealing papule or nodule, typically located on exposed parts of the body (eg, face, ears, arms, lower legs). The primary lesions usually enlarge slowly and may develop central ulceration. Although lesions may remain small (eg, up to a few centimeters in diameter), they may gradually enlarge and/or coalesce to become larger crusted plaques or ulcerations upwards of 10 cm in diameter. Large plaques usually have central ulceration or crusting, with a raised, indurated border.

Multiple primary lesions on one part of the body may be seen. Other variants include satellite lesions near a primary lesion (leishmania recidivans) and lesions that ascend the lymphatic chain (sporotrichoid spread).

In diffuse cutaneous leishmaniasis (DCL), look for disseminated, nonulcerative plaques and nodules, which can resemble the lesions of lepromatous leprosy.

Impact of skin color on clinical presentation: In darker skin colors, erythema can be difficult to discern. Lesions may appear pink, violaceous, gray, or dark brown. In lighter skin colors, lesions may appear any shade of pink or red. The border of an ulcer may also appear violaceous.

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