Cutaneous Leishmaniasis in a Central American Refugee

Abstract

Leishmaniasis is a zoonotic disease caused by an intracellular protozoan that is transmitted to humans following the bite of an infected female sand fly (1). An estimated 112 million people worldwide have leishmaniasis, with more than 400,000 new cases reported annually (2). Infection is endemic to certain geographic areas of the world, with the highest incidence in the Middle East, India, Nepal, Sudan, and certain countries in Central and South America (3,4). We report a case of cutaneous leishmaniasis in a 49year-old male who presented to our emergency room for evaluation of an ulcerative lesion on his finger. Microscopic examination of a Giemsa-stained touch preparation from the finger lesion showed intracellular protozoa suggestive of Leishmania species. The protozoan was recovered by culture from a biopsy specimen, and its identity was subsequently confirmed as Viannia (Leishmania) panamensis by using molecular methods. Case Report A 49-year-old non-English-speaking male presented to our emergency room for evaluation of an ulcerative lesion on the fifth finger of his left hand. Through a translator, it was determined that the patient was born in Cuba but spent most of his adult life traveling with others through the jungles of Panama and Colombia. He eventually arrived in the United States from Ecuador and resided for 3 months with relatives in the Syracuse, New York, area before his finger lesion was evaluated in our emergency room. The patient reported that initially, a very tiny black particle came out of the wound, followed by the development of the skin ulcer that progressively worsened (Fig. 1). The patient’s past medical history was unremarkable, except for an appendectomy several years previously. Physical examination was completely within normal limits, except for the presence of the painful, ulcerative lesion on his finger. An infectious disease physician was consulted for evaluation of the patient. Given his history of extensive and prolonged travel through the jungles of Central America, the initial diagnostic impression was that the patient might have cutaneous leishmaniasis. A touch preparation of the ulcerative skin lesion was prepared and stained by the Giemsa method. On microscopic examination, the smear showed the presence of intracellular protozoa (Fig. 2) that were highly suggestive of Leishmania species. A biopsy specimen from the lesion was submitted for testing to the Centers for Disease Control and Prevention, where a Leishmania species was recovered by culture. The protozoan was identified to the species level as Viannia (Leishmania) panamensis by using PCR and isoenzyme analyses. The patient was treated for 2 months with sodium stibogluconate (Pentostam), a pentavalent antimonial compound, with gradual resolution and healing of his finger lesion. Discussion