Cutaneous Leishmaniasis

Background: Leishmaniasis is a neglected tropical disease spread by the bite of the phlebotomine sand fly found typically in the tropics, subtropics and southern Europe. The two most common types of Leishmaniasis are cutaneous, which causes wounds in the skin, and visceral which affects internal organs (usually spleen, liver, bone marrow). While leishmaniasis is rare in the US, increasing trends of travel to tropical destinations necessitate awareness in dermatological and wound practices. 

Case study: 39-year-old healthy female developed a small red papular lesion on her left lower leg 6 months after vacationing in Cancun, Mexico. She did not recall having trauma or sand fly bites during her trip. She eventually developed a wound with ulcerated plaque, rolled borders and serous crusting 14 months post travel. Cutaneous Leishmaniasis mexicana, traced back to her visit to Cancun, was confirmed via PCR testing done at the CDC.  She was treated with 15% paromomycin topically BID for 4 weeks under occlusion, and ketoconazole 400 mg BID for 4 weeks which did not resolve the wound.  The 2.5 x 2.5 cm wound showed signs of healing, but was persistent with slightly erythematous edges and no evidence of granulation tissue one month after finishing treatment. Repeat biopsy showed no residual disease. She then underwent serial excisional debridements of the wound, in addition to starting enzymatic debridement with collagenase until robust granulation tissue developed. Collagen products were added weekly after granulation tissue was present. Eight weeks after debridements were started, the wound was healed. 

Conclusion: Patients presenting with wounds of unclear etiology should have travel history included in the history of present illness (HPI).  Differential diagnosis of atypical wounds should include parasitic etiologies, especially when travel history includes tropical locations.  Once the infection is treated, vigilant comprehensive wound care is required to heal the wound.