Cutaneous And Mucocutaneous Leishmaniasis Modes of Transmission : Vector-borne: by bite of infected female sandflies (2–3 mm long), which become infected by taking blood meal from infected mammalian host. Other modes: congenital and parenteral (i.e., by blood transfusion, needle sharing, laboratory accident). Incubation Period: Inversely proportional to size of inoculum: shorter in visitors to endemic area. OWCL: L. tropica major : 1–4 weeks. L. tropica , 2–8 months. acute CL: 2–8 weeks or more.

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Cutaneous And Mucocutaneous
Leishmaniasis

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Epidemiology
• Etiology :
Infection in humans is caused by ∼20
Leishmania species ( Leishmania and Viannia
subgenera).
• Stages of Parasite:
• Promastrigote: flagellated form found in
sandflies and culture.
• Amastigote: nonflagellated tissue form (2–4
μm in diameter); replicates in macrophage
phagosomes in mammalian hosts.

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Modes of Transmission :
1)Vector-borne: by bite of infected female
sandflies (2–3 mm long), which become
infected by taking blood meal from infected
mammalian host.
2)Other modes: congenital and parenteral
(i.e., by blood transfusion, needle sharing,
laboratory accident).

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Immune status of person
• Leishmania-specific anergy : patients
develop DCL(diffuse cutaneous leishmaniasis).
• Poor immune response or
immunosuppression (HIV/AIDS): VL (visceral
leishmaniasis).
• Hyperergic variant: Leishmaniasis
recidivans caused by L. tropica .

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Clinical Manifestation
• Incubation Period: Inversely proportional
to size of inoculum: shorter in visitors to
endemic area. OWCL:
• L. tropica major : 1–4 weeks.
• L. tropica , 2–8 months.
• acute CL: 2–8 weeks or more.

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Symptoms
• Nodulo-ulcerative lesions usually
asymptomatic.
• With secondary bacterial infection, may
become painful.

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Skin Findings
• Types of Lesions Primary lesions occur at site
of sandfly bite, usually on exposed site.
1. OWCL (Old World cutaneous leishmaniasis) L. major:
Begins as small erythematous papule, which
may appear immediately after sandfly bite but
usually 2–4 weeks later. Papule slowly
enlarges to 2 cm over a period of several
weeks .

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Old World cutaneous leishmaniasis: face
Large crusted nodules with surrounding edema on both
cheeks

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2. L. tropica:
Clinical pattern similar to that of L. major ,
although lesions caused by L. tropica are
more apt to be solitary, more inflammatory,
last longer, and be more difficult to treat.
3. NWCL L. mexicana Complex:
• Small erythematous papule develops at
sandfly bite site, evolving into ulcerated
nodule

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New World cutaneous
leishmaniasis: ulcer on thigh

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New World cutaneous leishmaniasis:
chiclero ulcer A deep ulcer on the helix at the site of a
sandfly bite

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Diagnosis ?
1) Clinical Diagnosis (Skin lesion )
2) Serology: Lacks specificity. Cannot distinguish
current from past infection.
3) Dermatopathology: Large macrophages filled
with 2- to 4-μm amastigotes (Leishman- Donovan
bodies); mixed lymphocytic, plasmacytic infiltrate. In
Wright- and Giemsa-stained.
4) Culture :Novy-MacNeal-Nicolle (NNN) medium at
22°C–28°C for 21 days grows motile promastigotes.

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4) Needle Aspiration: Visualize
amastigote within macrophages.
5) Polymerase Chain Reaction: Can
detect different species of Leishmania .
Specific and sensitive.

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Course And Prognosis
1) CL : Whether caused by L. tropica or L.
mexicana , CL is self-limited. Scarring is
increased by secondary bacterial infection.
2) MCL: May extend to secondary sites.
Superinfection common. Death from
pneumonia.
3) DCL : Progressive; refractory to treatment;
cures rare.

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Management
1. Prophylaxis:
No chemoprophylaxis for travelers exists.
• OWCL: Delay specific treatment until
ulceration occurs, allowing protective
immunity to develop, unless lesions are
disfiguring, disabling, persist ± 6 months.

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Goals:
Accelerating healing of skin lesions
Decreasing morbidity
Decreasing risk for local and mucosal
dissemination and relapse
Management of Cutaneous
Leishmaniasis

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Lesional Therapy
 Effective in some cases without local dissemination or
risk of mucosal dissemination (e.g., for relatively benign
lesions caused by L. Mexicana or L. major ).
 Topical imiquimod
 Paromomycin ointments (15% paramomycin sulfate,
12% methylbenzethonium chloride in white paraffin twice
daily for 10 days)
 Cryosurgery
 Ultrasound-induced hyperthermia
 Intralesional Pentostam given weekly up to1 mg/kg
injected into borders of lesions)

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Visceral Leishmaniasis:
1. Parenteral theraphy:
Pentavalent antimony
Amphotericin B, lipid formulation
Amphotericin B (deoxycholate)
Paromomycin sulfate
Pentamidine isethionate
2. Oral therapy:
Miltefosine

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Cutaneous Leishmaniasis:
1. Parenteral theraphy:
Pentavalent antimony
Pentamidine isethionate
Amphotericin B (deoxycholate)
2. Oral therapy:
Fluconazole
Ketoconazole

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Mucosal Leishmaniasis
Parenteral theraphy:
Pentavalent antimony
Pentamidine isethionate
Amphotericin B (deoxycholate)

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• SOURCE: From FITZPATRICK’S COLOR ATLAS
AND SYNOPSIS OF CLINICAL DERMATOLOGY
SIXTH EDITION

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