Leishmaniasis cutane (of the new world)B55.1

Leishmaniasis caused by Leishmania brasiliensis possibly with later spread to the mucous membranes of the upper respiratory tract (mucocutaneous form). According to the clinic a distinction is made between cutaneous and mucocutaneous form.

Cutaneous form: Initial formation of an erythematous papule with transition to central ulceration with formation of an elevated border wall. There is often an accompanying lymphangitis.

Mucocutaneous leishmaniasis: severe form of cutaneous leishmaniasis. Spread of the parasites from the original cutaneous lesions to the mucous membrane, probably hematogenic. Thickening in the nasal and lip area (tapir nose) with destruction of the septum, possible progression to the pharynx, larynx and trachea. This form occurs in 1-3% of infected persons and tends to superinfection with other pathogens.

• Cutaneous form: Often spontaneous healing.
• Mucocutaneous form: chronic recurrent course, risk of sepsis, mutilation, malnutrition
• Diffuse (anergic) cutaneous leishmaniasis

• A 41-year-old patient noticed 6 weeks after a backpacking holiday in Peru a solitary red scaly 0.5 cm large papule on the right lateral lower leg, which showed clear size progression over the course of several weeks. Furthermore, a central ulceration occurred after a banal injury.
• Findings: 3.0 cm large, centrally ulcerated, brown-red, slightly pressure swollen node on the right lateral lower leg. Clear lymphadenitis of the right groin.
• Histology: Acanthotic, sometimes pseudoepitheliomatous surface epithelium with parakeratotic serum crust. Dense, diffuse, granulomatous infiltrate of neutrophil granulocytes, epithelioid histiocytes and multinucleated giant cells of varying density, lymphocytes and numerous plasma cells. Especially in the Giemsa staining of fresh forms numerous intracellularly located pathogens are found.
• Culture: Leishmania braziliensis.
• Initial treatment with miltefosine (Impavido ®, 150mg/day p.o. for 28 days) resulted in a further progression of findings. Formation of additional red nodules along the proximal lymph channels.
• Change of therapy to liposomal amphotericin B (Ambisone 2.0-3.0-mg/kg/KG) over 10 days. Below this, complete reduction of the inguinal lymph node swelling. Scarred healing of the skin lesions.
• No recurrence in the follow-up period of 1 year.

1. Eichner S et al.(2011) Disseminated cutaneous leishmaniasis. Abstract CD 46th DDG meeting: P16/17
2. Vianna G (1911) Sobre uma nova especie de Leishmania. Bras Med 25: 411