Case Presentation:
My patient was a 64‐year‐old man with no significant past medical history who presented to Emergency department with a progressively worsening right dorsal foot soft tissue infection with a painless ulcer formation over 6 weeks‐old.
He had recently visited Bolivia and joined river fishing trip where he was bitten by a sandfly about 4 months prior to admission. The patient started to notice an erythematous papule on his right dorsal foot about 6 weeks prior to admission which was gradually getting bigger in size and swollen and erythematous. And in the last 4 weeks, the lesion was spreading thin and started to have a painless ulcer formation with a raised rim. This prompted the patient to see a primary infectious disease doctor. He was treated with total 4 antibiotics courses with broad spectrum coverage (Doxycycline→Augmentin→Ciprofloxacin → Linezolid→Bactrim) by a infectious disease specialist and a dermatologist without any improvement. Finally, patient was advised to come to emergency department for further work. He did not have a fever, chills, weight loss, night sweat, appetite loss, chest pain, shortness of breath, nausea, vomiting,or diarrhea through the clinical course. On admission, a physical examination revealed normal vital signs and a significant 3‐4 cm erythematous wound with a necrotic base and perilesional erythema with ulcer formation on right dorsal foot and patchy erythematous spreading to the thigh and sub centimeter right groin lymphadenopathy with tenderness. Admission lab findings were not significant. A vascular surgeon was called and did debridement and sent the sample to pathology and deep wound Cx which came back positive for Leishmaniasis. Given complications with lympthangitis, patient started liposomal amphotericin B IV for 7 days and was discharged. The patient has been followed as an outpatient and we’ve observed sign of healing.
Discussion:
Cutaneous leishmaniasis is the 10th most common dermatologic diagnosis among returned travelers but still there is some difficulty making a correct diagnosis, sometimes even by specialists. A definitive diagnosis is made by identifying amastigotes in tissue or promastigotes in culture, or by amplifying Leishmania‐specific DNA or RNA in a PCR. Most cases of cutaneous leishmaniasis will be resolved by themselves without any specific treatment but in some specific situations, especially people who have a higher risk of developing mucosal leishmaniasis, systemic treatment is recommended. There are no licensed drugs for treatment of cutaneous leishmaniasis in the U.S. Intramuscular SbV treatment is the most common with a overall 76% cure rate but there is difficulty in getting SbV from CDC. Even though there are no controlled studies, a recent small case series suggests liposomal amphotericin B can be used as a first choice drug which is commonly used among physicians.
Conclusions:
When we see the returned travelers who presented with antibiotics‐unresponsive ulcer, it is important to send the tissue samples for pathology, culture and PCR to make a correct diagnosis with cutaneous leishmaniasis and appropriately treat those who have a risk of developing mucosal leishmaniasis to prevent more serious complications
