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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.
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.
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.
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.
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.
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.
Cutaneous and mucocutaneous leishmaniasis: clinical perspectives.