Original Article
Cutaneous Leishmaniasis: 20 Years’ Experience in a Spanish Tertiary Care Hospital
Leishmaniasis cutánea. Experiencia de 20 años en un hospital español de tercer nivel
P. Giavedoni, P. Iranzo, I. Fuertes, T. Estrach, M. Alsina Gibert
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Servicio de Dermatología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
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Giavedoni, P. Iranzo, I. Fuertes, T. Estrach, M. Alsina Gibert" "autores" => array:5 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Giavedoni" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Iranzo" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Fuertes" ] 3 => array:2 [ "nombre" => "T." "apellidos" => "Estrach" ] 4 => array:4 [ "nombre" => "M." "apellidos" => "Alsina Gibert" "email" => array:1 [ 0 => "malsina@clinic.ub.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Leishmaniasis cutánea. Experiencia de 20 años en un hospital español de tercer nivel" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 746 "Ancho" => 996 "Tamanyo" => 164766 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Cutaneous leishmaniasis with multiple lesions.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Leishmaniasis is a widely distributed infectious parasitic disease. It is endemic in over 70 countries, although because disease notification is mandatory in just 32 of these, its true prevalence is probably underestimated.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The overall prevalence of leishmaniasis is 12 million cases worldwide, with an estimated annual incidence of 2 million cases (0.5 million cases of visceral leishmaniasis and 1.5 million cases of cutaneous leishmaniasis).<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a> Approximately 350 million people, many of whom are poor, are considered at risk for leishmaniasis. The countries with the greatest disease burden are Afghanistan, Brazil, Iran, Peru, Saudi Arabia, and Libya. In the Old World, prevalence is high in the Mediterranean area,<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4,5</span></a> and in Spain, leishmaniasis is considered to be endemic in the following autonomous communities: Andalusia, Aragon, the Balearic Islands, Cantabria, Castile and Leon, Catalonia, Valencia, Extremadura, Madrid, Murcia, Navarra, and La Rioja.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">According to the Spanish Epidemiological Surveillance Network, 1755 cases of leishmaniasis were reported in Spain between 1996 and 2011,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> corresponding to a mean annual incidence of 0.45 cases per 100 000 inhabitants. The number of cases is probably higher, as notification is mandatory only in regions in which the disease is considered endemic.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Based on the minimum data available for the period 2010-2011, leishmaniasis was the main diagnosis code recorded for 2739 hospitalized patients, 98 (3.6%) of whom had the cutaneous form of the disease.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A mean of 115 cases of leishmaniasis was reported in Spain between 2005 and 2010; this figure increased to 271 in 2011 (0.59 cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants) due to an outbreak of cases in Madrid (2.83 cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants).<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">There are 2 endemic <span class="elsevierStyleItalic">Leishmania</span> species in the Mediterranean area: <span class="elsevierStyleItalic">Leishmania infantum</span> and <span class="elsevierStyleItalic">Leishmania tropica</span>.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a><span class="elsevierStyleItalic">L infantum</span> is the only species in Spain. Cutaneous leishmaniasis is the most common clinical form of leishmaniasis,<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">8,9</span></a> and it typically manifests as self-limiting papules and nodules.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">An increase in incidence of imported leishmaniasis and leishmaniasis in immunodepressed patients has been reported in recent years<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> in relation to factors such as the presence of animal reservoirs, geographic mobility, and climate change, among others.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The profile of immunodepressed patients with leishmaniasis has changed over the years, with a reduction in the number of cases involving concomitant human immunodeficiency virus (HIV) infection and an increase in the number of patients with drug-induced immunosuppression, particularly in the following settings: organ transplantation, rheumatologic diseases, cancer, and hematological disorders.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The aim of this study was to analyze the epidemiological and clinical characteristics of patients diagnosed with cutaneous leishmaniasis in our hospital over the last 2 decades, with a particular focus on distinguishing clinical features in immunodepressed patients and patients with imported leishmaniasis.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Methods</span><p id="par0050" class="elsevierStylePara elsevierViewall">We conducted a retrospective study in which we reviewed epidemiological, clinical, microbiologic, and histologic data for 67 patients diagnosed with cutaneous leishmaniasis at the dermatology department of a tertiary level Spanish hospital between September 1992 and December 2012. Five of the patients also had visceral leishmaniasis. Relevant data were available for 54 patients, who were all included in our analyses. We compared data for 2 consecutive decades (1992-2002 and 2003-2012) to investigate whether there had been an increase in the number of cases of leishmaniasis and whether the introduction of immunosuppressant and immunomodulatory drugs such as biologics (which emerged mainly in the second decade) might be associated with changes in clinical presentation.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">Fifty-four patients were included in the study. The number of cases was similar in both decades, with a slightly higher number of patients treated in the second period (28 vs 26 patients).</p><p id="par0060" class="elsevierStylePara elsevierViewall">The median age was 43 years (range, 13-78 years), and there was a predominance of male patients (male to female ratio, 2.3:1). The mean time from onset of symptoms to the patient's visit was 3 months (range, 1 month-4 years).</p><p id="par0065" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the clinical and epidemiological characteristics of the patients analyzed.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Sixteen (29.62%) of the 54 patients were immunodepressed, with similar numbers seen in both decades. The causes of immunosuppression were lymphoproliferative disorders (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3), autoimmune diseases (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>4), HIV infection (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>7), immunosuppressant therapy (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>9), and biologic therapy (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2).</p><p id="par0075" class="elsevierStylePara elsevierViewall">Of the 7 cases of HIV and leishmaniasis coinfection, 4 were recorded between 1992 and 2002 and 3 between 2003 and 2012. In the second decade, there was a higher proportion of immunosuppressed patients receiving biologics, antitumor agents, and drugs to treat autoimmune disorders.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Nineteen patients (35%) were diagnosed with imported cutaneous leishmaniasis. They were from Jordan, Ecuador, Peru, Guatemala, Tunisia, Bolivia, Mauritania, Venezuela, Iran, Israel, India, and Morocco. The number of cases was higher in the second decade (11/19 vs 8/19) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><p id="par0085" class="elsevierStylePara elsevierViewall">Eighty-one lesions were analyzed. Plaques and ulcers were the most common type (26% and 33%, respectively) and both were more common in the second decade. The rest of the lesions (41%) were macules, papules, or nodules. Thirty-two patients (59%) had more than 2 lesions, and were therefore considered to have the multiple form of cutaneous leishmaniasis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Four patients (2 in each decade) had oral and/or nasal mucosal involvement due to the contiguity of the facial lesions.</p><p id="par0095" class="elsevierStylePara elsevierViewall">All these cases occurred in patients who did not mention having traveled abroad. <span class="elsevierStyleItalic">L infantum</span> was identified by polymerase chain reaction (PCR) in 1 case. The patients were therefore diagnosed with mucocutaneous leishmaniasis due to <span class="elsevierStyleItalic">L infantum</span>. Two of the patients were immunocompetent and 2 were immunodepressed. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> summarizes the characteristics of the patients by immune status. Of the 16 immunodepressed patients, 10 (62.5%) had multiple lesions and the same number had ulcerative lesions. In the group of 19 patients with imported leishmaniasis, 12 (63%) had multiple lesions and 15 (78%) had ulcers (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Twelve (33%) of the 36 immunocompetent patients had multiple lesions and 4 (11%) had ulcerative lesions. The corresponding numbers in the group of 32 patients with autochthonous leishmaniasis were 12 patients with multiple lesions (31%) and 2 with ulcerative lesions (6.25%).</p><p id="par0105" class="elsevierStylePara elsevierViewall">Diagnosis in the first decade was based on clinical and pathologic findings in all cases. Hematoxylin-eosin staining was performed in 41 cases and Giemsa staining in just 3.</p><p id="par0110" class="elsevierStylePara elsevierViewall">In the second decade, diagnosis was confirmed by molecular techniques in 11 patients. PCR analysis identified the species in 6 patients, 5 of whom were infected with <span class="elsevierStyleItalic">L infantum</span>. The sixth patient, from Jordan, was infected with <span class="elsevierStyleItalic">L tropica.</span></p><p id="par0115" class="elsevierStylePara elsevierViewall">The patients were treated with pentavalent antimonials, namely, intralesional meglumine antimonate in 32 cases and intramuscular meglumine antimonate (20<span class="elsevierStyleHsp" style=""></span>mg/kg/d for 21 days) in 16 cases.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Intralesional meglumine antimonate was used to treat patients with single lesions measuring less than 3<span class="elsevierStyleHsp" style=""></span>cm and patients with 5 or fewer lesions. Systemic treatment was used in all other cases.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Just 1 patient, who was treated with intramuscular meglumine antimonate, developed serious adverse effects, consisting of supraventricular arrhythmia, elevated liver and pancreatic enzyme levels, and acute kidney failure. Treatment was therefore discontinued at 2 weeks, but despite this, the lesions resolved. We do not know if the infection was cured, as the patient died due to worsening of his underlying condition. Treatment with meglumine antimonate was completed without complications in the remaining patients.</p><p id="par0130" class="elsevierStylePara elsevierViewall">In the second decade, 7 patients were treated on days 1 to 5, 14, and 21 with intravenous liposomal amphotericin B at a dose of 3 to 4<span class="elsevierStyleHsp" style=""></span>mg/kg/d, depending on the patient's immune status.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> The lesions healed in 3 cases. The 4 nonresponders were subsequently treated with intramuscular meglumine antimonate at the standard dose. Complete response was observed in 3 of these patients. The fourth patient, who had severe HIV-associated immunosuppression, showed improvement, but died from reasons unrelated to leishmaniasis or leishmaniasis treatment.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Thirty-nine patients (74%) were followed clinically for at least 14 months. Cure was confirmed in 35 of these (65%), all of whom were asymptomatic at the 1-year follow-up visit. All of the patients who were not seen in follow-up had a single cutaneous lesion.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">Leishmaniasis is a parasitic infection that is endemic in the Mediterranean area. The number of cases is expected to rise in coming years due to an increase in animal reservoirs (infected domestic dogs),<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a> immunodepressed hosts, migratory movements, and global warming.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">It has been estimated that approximately 75% of new cases of leishmaniasis are cutaneous.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In our study, which compared data for 1992-2002 and 2003-2012, we observed a slightly higher incidence of cutaneous leishmaniasis cases in the second decade (28 vs 26 cases)</p><p id="par0155" class="elsevierStylePara elsevierViewall">There was a predominance of male patients in our series, supporting previous reports.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a> Although leishmaniasis is considered a predominantly infantile disease, all the patients in our series were adults, as we do not treat children at our hospital.</p><p id="par0160" class="elsevierStylePara elsevierViewall">The incidence of leishmaniasis in immunodepressed patients was similar in both decades; this observation contrasts with previous reports that predicting an increase in cases in this setting.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> Antiretroviral drugs were introduced into Spanish hospitals—ours included—at the end of 1996, with full implementation in 1997. It is therefore possible that the number of patients with severely compromised immune systems due to HIV infection leveled off in the second decade, explaining the reduction in cases of cutaneous leishmaniasis observed in this group of patients. Our small sample size could also explain why we did not observe significant differences. The prevalence of leishmaniasis imported from the Old World in our series (60%) also contrasts with reports by many authors describing more cases of leishmaniasis imported from the New World.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Typical skin manifestations due to <span class="elsevierStyleItalic">L infantum</span> infection in immunocompetent patients are self-limiting solitary or multiple papules, plaques or nodules, which may develop ulcers.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> We observed similar skin manifestations in our series, but it is worth noting that the majority of immunodepressed patients and patients with imported leishmaniasis had multiple and/or ulcerative lesions. We therefore recommend ruling out immunodepression and infection by imported strains in patients with multiple and/or ulcerative skin lesions.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Delayed diagnoses are common in leishmaniasis.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a> In our series, the mean time from the onset of symptoms to diagnosis was 3 months. The differential diagnosis is broad and includes skin conditions such as insect bites, bacterial and mycobacterial infections, and even granulomatous disorders. Leishmaniasis is diagnosed by histology, culture, and molecular analysis. Histologic features include <span class="elsevierStyleItalic">Leishmania</span> amastigotes in macrophages in the upper dermis and a lymphoplasmacytic inflammatory infiltrate. A diagnosis can be reached with hematoxylin-eosin staining, but Giemsa staining is also useful. Novy-MacNeal-Nicolle medium is the standard culture medium used to diagnose leishmaniasis. This medium, however, is not widely used at our hospital due to its low yield and the slow growth of <span class="elsevierStyleItalic">Leishmania</span> species. Molecular techniques, and PCR in particular, are among the most sensitive techniques for the diagnosis of cutaneous leishmaniasis.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Diagnosis was confirmed by histology in the first decade of our study. In the second decade, 20% of cases were confirmed by molecular analysis, which additionally identified the species in 54% of these. Species identification is particularly important in the case of imported leishmaniasis, as it helps to guide treatment and predict clinical course. Leishmaniasis originating in Central America requires systemic treatment to prevent mucosal involvement and lymphatic spread (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). When molecular techniques are not available, however, a thorough history and histologic examination are essential diagnostic tools.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">Treatment with meglumine antimonate was effective in most cases. Multiple adverse effects have been described in patients treated with systemic meglumine antimonate<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> and include myalgia, joint pain, increased pancreatic enzyme levels, exanthema, nausea, abdominal pain, fatigue, headache, increased liver transaminases, leukopenia, and nonspecific ST segment elevation on electrocardiography.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a> Meglumine antimonate proved safe and effective in our series of patients and only needed to be discontinued in 1 patient who developed serious adverse effects due to systemic therapy.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Pentavalent antimonials remain the treatment of choice for both localized and generalized cutaneous leishmaniasis, regardless of the patient's immune status.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">10,19,20</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Liposomal amphotericin B is particularly effective in visceral leishmaniasis, and in our series it was partly effective in cutaneous leishmaniasis.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Four of the 7 patients treated with liposomal amphotericin B showed no improvement, but they did show partial response to subsequent treatment with intramuscular meglumine antimonate.</p><p id="par0200" class="elsevierStylePara elsevierViewall">It has been known since the 1990s that a high percentage of cases of cutaneous leishmaniasis from the Old Word heal spontaneously. Furthermore, good results have been reported in studies of local treatments such as cryotherapy, paromomycin ointment, and intralesional antimonials. Intralesional meglumine antimonial administered at a dose of 0.5 to 3<span class="elsevierStyleHsp" style=""></span>mL three times a week over 4 to 5 weeks is currently considered the first-line treatment for most cases of leishmaniasis and has proven effective in <span class="elsevierStyleItalic">L infantum</span> infections in the Mediterranean area (recommendation and evidence rating BII).<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a> Adverse effects reported for intralesional meglumine antimonate include local allergic reactions, pain, swelling, pruritus, and transient erythema. Intralesional therapy is not recommended for certain locations such as the fingers, ears, lips, and nose.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Combined local and systemic treatment has proven superior to either of these treatments administered alone. Oral treatments, namely azoles and miltefosine, reduce costs associated with hospitalization. Response to these drugs, however, is limited, and current knowledge is confined to a series of patients in whom other treatments had previously failed.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Systemic treatment is the treatment of choice for New World cutaneous leishmaniasis, although local treatment could be considered in specific situations. The effectiveness of each drug depends on the species of <span class="elsevierStyleItalic">Leishmania</span> and the geographic region. Pentavalent antimonials are the most widely used drugs, but they have many adverse effects and require long treatment periods. The recommended treatment for mucocutaneous leishmaniasis from the New World is meglumine antimonate in association with pentoxifylline for a period of 30 days.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">15,21,23</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">In our series, 25% of patients were lost to follow-up. Most of these had a single skin lesion and had been treated with intralesional meglumine antimonate and/or cryotherapy. We therefore assume that cure would have been achieved in most of these cases. Four patients died during the study period, but none of the deaths were related to leishmaniasis or leishmaniasis treatment.</p><p id="par0220" class="elsevierStylePara elsevierViewall">In conclusion, we did not detect an increase in the number of cases of cutaneous leishmaniasis or an increase in the number of immunodepressed patients with leishmaniasis over the last 2 decades. We recommend assessing immune status and ruling out infection by imported <span class="elsevierStyleItalic">Leishmania</span> species in patient with multiple and/or ulcerative lesions.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethical Disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protection of humans and animals</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare that no tests were carried out in humans or animals for the purpose of this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Confidentiality of data</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors declare that they have followed their hospital's protocol on the publication of data concerning patients.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Right to privacy and informed consent</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data appear in this article.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of Interest</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres494700" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec515926" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres494699" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec515927" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of humans and animals" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of Interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-07-24" "fechaAceptado" => "2014-12-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec515926" "palabras" => array:4 [ 0 => "Leishmaniasis" 1 => "Cutaneous" 2 => "Immunodepressed" 3 => "Meglumine antimonate" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec515927" "palabras" => array:4 [ 0 => "Leishmaniasis" 1 => "Cutánea" 2 => "Inmunodeprimido" 3 => "Antimoniato de meglumina" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cutaneous leishmaniasis is the most common form of leishmaniasis, which is endemic in Spain. The aim of this study was to evaluate the epidemiological and clinical characteristics of cutaneous leishmaniasis seen in our hospital over a period of 20 years, with a particular focus on clinical differences according to immune status and origin of infection</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We performed a chart review of 67 cases of cutaneous leishmaniasis diagnosed between 1992 and 2012. Follow-up data were available for 54 patients.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Fifty-four patients with cutaneous leishmaniasis were included in the study. Of these, 26 had been diagnosed between 1992 and 2002 and 28 between 2003 and 2012.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The mean age at diagnosis was 49 years, there was a predominance of male patients, and the mean time from onset of symptoms to consultation was 3 months. The most common clinical manifestations were plaques and ulcers. Most of the immunodepressed patients and patients with imported leishmaniasis had skin ulcers and/or multiple lesions. During the first decade of the study, diagnosis was based on clinical and histologic findings. These were supported by molecular techniques in the second decade. Pentavalent antimonials were the treatment of choice, producing good results and very few adverse effects</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The number of patients with cutaneous leishmaniasis and with compromised immune status was similar in the periods 1992-2002 and 2003-2013, but more cases of imported leishmaniasis were diagnosed in the second period. Patients with ulcers and/or multiple lesions should be evaluated to rule out immunosuppression or infection by <span class="elsevierStyleItalic">Leishmania</span> species from other parts of the world. Both systemic and intralesional meglumine antimonate was effective and safe</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción y objetivos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La leishmaniasis es endémica en España, siendo la leishmaniasis cutánea la forma más habitual de presentación. El objetivo del estudio fue valorar las características epidemiológicas y clínicas de la leishmaniasis cutánea en las últimas 2 décadas, haciendo hincapié en las diferencias clínicas según el estado inmunitario del paciente y el origen de la infección.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y métodos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se revisaron retrospectivamente 67 historias clínicas de pacientes diagnosticados de leishmaniasis entre 1992 y 2012, de ellas 54 eran cutáneas, y con datos de seguimiento.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 54 pacientes: 26 diagnosticados entre 1992-2002 y 28 entre 2003-2012.</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La edad media fue de 49 años, con un predominio en varones y un tiempo medio de evolución previo a la consulta de 3 meses. Las manifestaciones clínicas más frecuentes fueron placas y úlceras. La mayoría de pacientes inmunodeprimidos y con leishmaniasis importada presentaron lesiones ulceradas y/o múltiples. El diagnóstico se basó en los hallazgos clínico-patológicos en la primera década, asociándose el diagnóstico por métodos moleculares en la segunda. El tratamiento de elección fue los antimoniales pentavalentes, con buenos resultados y escasos efectos adversos.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El número de casos y de pacientes inmunodeprimidos fueron similares en ambas décadas, diagnosticándose un mayor número de leishmaniasis importada en la segunda. En los pacientes con lesiones múltiples y/o ulceradas deberían descartarse la inmunosupresión del huésped y la infección por cepas importadas. El tratamiento con antimoniato de meglumina fue eficaz y seguro, tanto por vía sistémica como intralesional.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Giavedoni P, Iranzo P, Fuertes I, Estrach T, Alsina Gibert M. Leishmaniasis cutánea. Experiencia de 20 años en un hospital español de tercer nivel. Actas Dermosifiliogr. 2015;106:310–316.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 746 "Ancho" => 996 "Tamanyo" => 164766 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Cutaneous leishmaniasis with multiple lesions.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 744 "Ancho" => 995 "Tamanyo" => 160812 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Imported cutaneous leishmaniasis with ulcerative lesions from Central America.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 747 "Ancho" => 995 "Tamanyo" => 127450 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Multiple lesions in imported cutaneous leishmaniasis.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col">Clinical and Immunological Data \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">No. of Patients</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Total \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">1992-2002 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">2003-2012 \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">54 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">26 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">28 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Immune status \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Immunocompetent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Immunodepressed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Source of infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Autochthonous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Imported \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Clinical presentation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Macule/papule/nodule \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Plaque \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ulcer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mucosa \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Solitary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab785756.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Clinical and Epidemiological Data in 54 Patients With Cutaneous Leishmaniasis.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Multiple Lesions, No. (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ulcerative Lesions, No. (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Multiple and Ulcerative Lesions, No. (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Immunocompetent patients (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>36) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (33) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (8.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Immunodepressed patients (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (62.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (62.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (37.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Autochthonous leishmaniasis (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (46.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (15.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (15.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Imported leishmaniasis (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (63) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (66.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (66.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Immunodepressed patients with autochthonous leishmaniasis (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (46.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (15.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (15.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Immunodepressed patients with imported leishmaniasis (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (66.66) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (66.66) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab785757.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Classification of 54 Cases of Cutaneous Leishmaniasis According to Source of Infection and Immune Status.</p>" ] ] 5 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">No. of Patients</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Total \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">1992-2002 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">2003-2012 \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">54 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">28 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">26 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Diagnosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Clinical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Histology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Molecular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intralesional glucantime \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intramuscular glucantime \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Liposomal amphotericin B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Clinical Outcome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Death \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Loss to follow-up \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab785758.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Diagnosis, Treatment, 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 9 | 14 |
| 2024 October | 79 | 42 | 121 |
| 2024 September | 92 | 31 | 123 |
| 2024 August | 118 | 59 | 177 |
| 2024 July | 76 | 30 | 106 |
| 2024 June | 84 | 32 | 116 |
| 2024 May | 66 | 30 | 96 |
| 2024 April | 77 | 26 | 103 |
| 2024 March | 51 | 32 | 83 |
| 2024 February | 62 | 27 | 89 |
| 2024 January | 48 | 35 | 83 |
| 2023 December | 57 | 16 | 73 |
| 2023 November | 59 | 24 | 83 |
| 2023 October | 57 | 19 | 76 |
| 2023 September | 69 | 28 | 97 |
| 2023 August | 55 | 14 | 69 |
| 2023 July | 73 | 53 | 126 |
| 2023 June | 57 | 25 | 82 |
| 2023 May | 72 | 21 | 93 |
| 2023 April | 56 | 18 | 74 |
| 2023 March | 67 | 19 | 86 |
| 2023 February | 55 | 25 | 80 |
| 2023 January | 46 | 27 | 73 |
| 2022 December | 59 | 42 | 101 |
| 2022 November | 48 | 41 | 89 |
| 2022 October | 26 | 22 | 48 |
| 2022 September | 28 | 49 | 77 |
| 2022 August | 26 | 48 | 74 |
| 2022 July | 24 | 39 | 63 |
| 2022 June | 21 | 23 | 44 |
| 2022 May | 36 | 54 | 90 |
| 2022 April | 45 | 39 | 84 |
| 2022 March | 40 | 40 | 80 |
| 2022 February | 33 | 45 | 78 |
| 2022 January | 34 | 32 | 66 |
| 2021 December | 36 | 38 | 74 |
| 2021 November | 47 | 41 | 88 |
| 2021 October | 35 | 52 | 87 |
| 2021 September | 41 | 37 | 78 |
| 2021 August | 41 | 31 | 72 |
| 2021 July | 26 | 34 | 60 |
| 2021 June | 46 | 26 | 72 |
| 2021 May | 34 | 26 | 60 |
| 2021 April | 60 | 61 | 121 |
| 2021 March | 75 | 15 | 90 |
| 2021 February | 76 | 32 | 108 |
| 2021 January | 43 | 23 | 66 |
| 2020 December | 44 | 20 | 64 |
| 2020 November | 29 | 26 | 55 |
| 2020 October | 37 | 15 | 52 |
| 2020 September | 30 | 11 | 41 |
| 2020 August | 17 | 10 | 27 |
| 2020 July | 58 | 15 | 73 |
| 2020 June | 38 | 31 | 69 |
| 2020 May | 23 | 20 | 43 |
| 2020 April | 28 | 17 | 45 |
| 2020 March | 36 | 23 | 59 |
| 2020 February | 7 | 1 | 8 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 5 | 13 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 4 | 3 | 7 |
| 2019 August | 4 | 5 | 9 |
| 2019 July | 4 | 4 | 8 |
| 2019 June | 4 | 10 | 14 |
| 2019 May | 6 | 29 | 35 |
| 2019 April | 2 | 12 | 14 |
| 2019 March | 4 | 12 | 16 |
| 2019 February | 2 | 1 | 3 |
| 2019 January | 4 | 1 | 5 |
| 2018 December | 3 | 5 | 8 |
| 2018 October | 4 | 0 | 4 |
| 2018 September | 4 | 0 | 4 |
| 2018 March | 3 | 2 | 5 |
| 2018 February | 17 | 6 | 23 |
| 2018 January | 29 | 3 | 32 |
| 2017 December | 35 | 8 | 43 |
| 2017 November | 20 | 1 | 21 |
| 2017 October | 26 | 7 | 33 |
| 2017 September | 16 | 6 | 22 |
| 2017 August | 16 | 3 | 19 |
| 2017 July | 20 | 9 | 29 |
| 2017 June | 24 | 5 | 29 |
| 2017 May | 22 | 4 | 26 |
| 2017 April | 22 | 9 | 31 |
| 2017 March | 7 | 11 | 18 |
| 2017 February | 19 | 10 | 29 |
| 2017 January | 34 | 12 | 46 |
| 2016 December | 26 | 13 | 39 |
| 2016 November | 47 | 13 | 60 |
| 2016 October | 28 | 17 | 45 |
| 2016 September | 0 | 5 | 5 |
| 2016 July | 11 | 1 | 12 |
| 2016 June | 11 | 4 | 15 |
| 2016 May | 11 | 1 | 12 |
| 2016 April | 12 | 5 | 17 |
| 2016 March | 12 | 0 | 12 |
| 2016 February | 7 | 3 | 10 |
| 2016 January | 14 | 5 | 19 |
| 2015 December | 17 | 0 | 17 |
| 2015 November | 8 | 1 | 9 |
| 2015 October | 1 | 0 | 1 |
| 2015 September | 0 | 6 | 6 |
| 2015 August | 0 | 5 | 5 |
| 2015 July | 4 | 9 | 13 |
| 2015 June | 5 | 7 | 12 |
| 2015 May | 9 | 9 | 18 |
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