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14-year-old female with nonhealing wounds on bilateral upper, lower extremities
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A 14-year-old female presented to the pediatric dermatology clinic for evaluation of several nontender, nonhealing wounds on her bilateral upper and lower extremities that have been present for about 6 months.
Figure 1. Patient exhibits pinkish-red papules with raised edges and central-crusted ulcerations.
Source: Krakowski AC
Figure 2-3. Papules were located on patient’s upper and lower extremities.
Source: Krakowski AC
A bacterial culture taken from a skin swab of one of the lesions exhibited 3+ gram-positive Staphylococcus aureus. Of note, the girl is an avid saltwater angler. The family also owns a hot tub, and the patient uses it “about three times a week.” The patient also stated that she only noticed the lesions after returning to the United States from a 4-week trip to Israel, during which, she had spent several days camping outdoors in the Negev Desert and noted multiple “bug bites.” In addition, the patient’s family had recently adopted a rescue dog from a local shelter.
On physical exam, the patient had six pinkish-red papules with raised edges and central-crusted ulcerations scattered over her distal upper and lower extremities.
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Case Discussion
Answer: A. – False. Leishmaniasis is a vector-borne disease caused by protozoa of the genus Leishmania with disease manifestations that range from localized skin ulceration to lethal visceral disease. The global incidence of leishmaniasis is estimated to be near 2 million cases annually, with cutaneous leishmaniasis accounting for the vast majority of cases and having a wider geographic distribution.
Laura F. Sandoval
Andrew C. Krakowski
With increased global travel and provider awareness, “imported” cases of leishmaniasis are becoming more commonly diagnosed in developed, nonendemic countries, posing new challenges for treating physicians given the lack of evidence-based data or universal treatment guidelines.
Several bacterial cultures isolated S. aureus in the patient’s wounds; this did not deter the patient’s clinical team from pursuing a further work-up because the rate of secondary bacterial infection within cutaneous leishmaniasis wounds has been reported to be as high as 20%. Based on the morphology of the patient’s lesions and her strong travel history, a skin biopsy was performed, and PCR testing by the CDC — a resource available to U.S. clinicians for reference diagnostic services for this disease — confirmed infection by Leishmania major.
The patient was diagnosed with cutaneous leishmaniasis and — per recommendations made by infectious disease specialists in San Diego, Israel, and the CDC — she was started on a 6-week course of oral fluconazole 400 mg daily in combination with once daily topical paromomycin to all of her lesions. At 2-month follow-up, all of her lesions had healed completely.
- References:
- Alvar J, et al. PLoS One. 2012;doi:10.1371/journal.pone.0035671.
- Pavli A, et al. Int J Infect Dis. 2010;doi:10.1016/j.ijid.2010.06.019.
- Ziaie H, et al. Indian J Dermatol. 2008;doi:10.4103/0019-5154.43217.
- For more information:
- Laura F. Sandoval, DO, is a second-year dermatology resident at Sampson Regional Medical Center, in Clinton, N.C. She can be reached at lsandovaldo10@gmail.com.
- Andrew C. Krakowski, MD, is chief medical officer of DermOne in West Conshohocken, Pa.
Disclosures: Sandoval and Krakowski report no relevant financial disclosures.