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Cutaneous Leishmaniasis in a Boy from Belize

Published:September 27, 2018DOI:https://doi.org/10.1016/j.jpeds.2018.08.057
      A 9-year-old boy from Belize presented with a 3-month history of enlarging plaques on his arm. Originating as papules, the lesions had progressed despite treatment with topical mupirocin, oral amoxicillin, and cephalexin. At presentation, physical examination revealed 2 well-circumscribed, round plaques with rolled borders and central erosion on the right forearm (Figure 1). A previous biopsy demonstrated amastigotes within histiocytes, consistent with a diagnosis of cutaneous leishmaniasis. Repeat biopsy sent for polymerase chain reaction, conducted by the Centers for Disease Control and Prevention (CDC), confirmed infection by Leishmania mexicana.
      Figure 1
      Figure 1Ulcerated plaques on the right forearm due to localized cutaneous leishmaniasis. The patient presented with 2 well-circumscribed plaques, which had rolled borders surrounding central erosions with overlying serous crusts, on the right forearm. Biopsy and subsequent speciation by polymerase chain reaction conducted by the CDC, confirmed infection by L mexicana.
      Leishmaniasis is a protozoal infection transmitted from the bite of sandflies of the Lutzomyia and Phlebotomus genera. Although historically a disease of the tropics, globalization has expanded its presence.
      • Handler M.
      • Patel P.
      • Kapila R.
      • Al-Qubati Y.
      • Schwartz R.
      Cutaneous and mucocutaneous leishmaniasis: clinical perspectives.
      Although less commonly affected than adults, children represent a uniquely vulnerable population, given their propensity for outdoor activities.
      • Paniz-Mondolfi A.
      • Talhari C.
      • Garcia Bustos M.
      • Rosales T.
      • Villamil-Gomez W.E.
      • Marquez M.
      • et al.
      American cutaneous leishmaniasis in infancy and childhood.
      The presentation and course of disease vary greatly depending on the patient's immune status and the infecting species, which are classified according to geographic distribution.
      Old World species include those endemic to the Eastern hemisphere. Infection typically results in localized cutaneous leishmaniasis, which manifests as an enlarging papulonodule. Subsequent ulceration produces the characteristic “pizza-like” lesion, with rolled borders surrounding a central crusted plaque or ulcer, which eventually self-heals. Organisms originating from Central and South America are referred to as New World species. Infection may cause localized cutaneous leishmaniasis but also can progress into more widespread diseases due to the dissemination of parasites from the skin to the mucosa (mucosal leishmaniasis) or the reticuloendothelial system (visceral leishmaniasis).
      L mexicana, though classified as a New World species, typically causes symptomatology resembling that of Old World disease. Most patients experience localized plaque or ulcer formation, which spontaneously resolves within months. However, immunocompromised individuals may succumb to a disseminated form of cutaneous disease that, in severe cases, also can affect the mucosa.
      • Paniz-Mondolfi A.
      • Talhari C.
      • Garcia Bustos M.
      • Rosales T.
      • Villamil-Gomez W.E.
      • Marquez M.
      • et al.
      American cutaneous leishmaniasis in infancy and childhood.
      Diagnosis can be achieved through visualization of Leishmania amastigotes within histiocytes (Leishman–Donovan bodies).
      • James W.
      • Berger T.
      • Elston D.
      • Elston D.M.
      Parasitic infestations, stings, and bites.
      However, identification of these structures can prove difficult. Thus, diagnosis should be confirmed through multiple means. Speciation also should be performed, as it aids in predicting the clinical course and guiding treatment. For cases of cutaneous leishmaniasis, the CDC recommends performing a punch biopsy at the edge of an ulcer and then trisecting the tissue. Sections should be used for histologic examination and tissue impression smears. One portion should be submitted to the CDC for culture on Novy–MacNeal–Nicolle medium and speciation through polymerase chain reaction analysis.
      • Handler M.
      • Patel P.
      • Kapila R.
      • Al-Qubati Y.
      • Schwartz R.
      Cutaneous and mucocutaneous leishmaniasis: differential diagnosis, diagnosis, histopathology, and management.
      There are several options available for the treatment of localized cutaneous disease due to L mexicana, including cryotherapy, topical paromomycin, and intralesional meglumine antimonite.
      • Handler M.
      • Patel P.
      • Kapila R.
      • Al-Qubati Y.
      • Schwartz R.
      Cutaneous and mucocutaneous leishmaniasis: differential diagnosis, diagnosis, histopathology, and management.
      However, each is limited in efficacy and carries a risk of side effects. In addition, most cases of localized disease will eventually self-resolve. Thus, some have advocated for a period of observation before initiation of therapy.
      • Paniz-Mondolfi A.
      • Talhari C.
      • Garcia Bustos M.
      • Rosales T.
      • Villamil-Gomez W.E.
      • Marquez M.
      • et al.
      American cutaneous leishmaniasis in infancy and childhood.
      Following conservative treatment, with careful wound care and close follow-up, the lesions improved at both 1 (Figure 2; available at www.jpeds.com) and 3 months (Figure 3; available at www.jpeds.com), and the patient developed no evidence of mucosal disease.
      Figure 2
      Figure 2Clinical appearance of plaques at 1-month follow up.
      Figure 3
      Figure 3Clinical appearance of plaques at 3-month follow up. The patient's plaques showed dramatic improvement with conservative treatment involving careful wound care and close observation. He developed no evidence of mucosal disease.

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