New World Cutaneous Leishmaniasis: Obstacles in Initiating Treatment With Sodium Stibogluconate in 2 Travelers From Texas
April 2013 | Volume 12 | Issue 4 | Case Reports | 476 | Copyright © April 2013
Melissa D. Darling MD,a Jason S. Reichenberg MD,b and Alde Carlo P. Gavino MDb
aDepartment of Dermatology, Texas Tech University Health Sciences Center, Lubbock, TX
bDepartment of Dermatology, The University of Texas Southwestern-Austin, Austin, TX
New World cutaneous leishmaniasis (CL) is considered in the differential diagnosis for patients with nonhealing ulcers and a history of travel to high-risk areas. For patients at risk for progression to mucocutaneous leishmaniasis, first-line treatment in the United States entails the use of sodium stibogluconate (SSG), which is obtained from the Centers for Disease Control and Prevention (CDC) under an investigational drug protocol. We report 2 cases of New World CL in travelers to endemic areas who were diagnosed and treated with SSG. These cases demonstrate the logistics of coordinating with the CDC to definitively diagnose New World CL and initiate the necessary treatment. J Drugs Dermatol.
Cutaneous leishmaniasis (CL) is a vector-borne protozoan infection transmitted by the bite of infected sandflies. The disease can be seen in 2 forms; the first, Old World CL, is caused by species in the Middle East, Asia, Africa, and southern Europe, and the second, New World CL, is caused by species in Mexico, Central America, and South America. Mucosal leishmaniasis is a rare complication of New World CL resulting from dissemination of parasites to the naso-oropharyngeal mucosae, primarily seen during infection with Leishmania braziliensis and to a lesser extent Leishmania panamensis and Leishmania guyanensis.1 US clinicians can see cases of New World CL in immigrants, travelers, and military personnel; occasionally, patients may acquire the infection in Texas and Oklahoma.2,3
The first sign of an infection by New World CL is typically a small area of erythema that develops where an infected sandfly has bitten the host. Over a period of 2 weeks to 6 months, the erythema develops into a papule, then a nodule that progressively ulcerates.4 Subcutaneous nodules can form satellites or extend along lines of lymphatic drainage.4,5 Among the species that cause mucosal leishmaniasis, only a minority disseminate. The risk of dissemination from L braziliensis ranges from less than 5% to 12.8%, depending on the study.1,6 Clinical manifestations may include nasal inflammation, mucosal ulceration, perforation of the septum, and rare involvement of the lips, cheeks, soft palate, pharynx, or larynx. The risk of mucosal involvement is a primary motivation for systemic treatments.
First-line treatment of New World CL is 20 days of parenteral sodium stibogluconate (SSG), a pentavalent antimony compound used for treatment of all forms of leishmaniasis (except L guyanensis, where pentamidine is first-line). Due to limited demand for the drug in the United States, however, SSG is not approved by the US Food and Drug Administration and is only available through the Centers for Disease Control and Prevention (CDC) under the Investigational New Drug protocol.7 In this report, we discuss 2 cases of New World CL in travelers to endemic areas as well as the logistics of coordinating with the CDC for diagnosis and treatment with SSG.
Our first patient is a 21-year-old Caucasian man who spent the month of December in Bolivia and Peru. After being home for 2 months, he presented to our clinic with a 1-month history of a red papule on his right forearm that evolved into a pustule and eventually a 2-cm ulcerated plaque with an erythematous raised border and yellow exudates (Figure 1). A culture of the lesion grew methicillin-sensitive Staphylococcus aureus that was subsequently treated with trimethoprim-sulfamethoxazole. A punch biopsy on hematoxylin and eosin (H&E)–prepared permanent sections revealed extensive erosion, dermal necrosis, and Leishmania-type organisms; Giemsa-stained sections highlighted a moderate number of amastigotes. Nine days later, 2 more punch biopsies were sent to the CDC for culture, isoenzyme typing, and polymerase