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Cutaneous and mucocutaneous leishmaniasis: Differential diagnosis, diagnosis, histopathology, and management

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The diagnosis of leishmaniasis can be challenging because it mimics both infectious and malignant conditions. A misdiagnosis may lead to an unfavorable outcome. Using culture, histologic, and/or polymerase chain reaction study results, a diagnosis of leishmaniasis can be established and treatment initiated. Appropriate management requires an accurate diagnosis, which often includes identification of the specific etiologic species. Different endemic areas have varying sensitivities to the same medication, even within individual species. Species identification may be of practical value, because infections with select species have a substantial risk of visceral involvement. In addition, HIV and otherwise immunocompromised patients with leishmaniasis have a propensity for diffuse cutaneous leishmaniasis. For most New World Leishmania species, parenteral antimonial drugs remain the first line of therapy, while Old World species are easily treated with physical modalities. Historically, live organism vaccination has been used and is effective in preventing leishmaniasis, but results in an inoculation scar and an incubation period that may last for years. A more effective method of vaccination would be welcome.

Section snippets

Differential diagnosis

Key points

  1. Leishmaniasis may mimic other infectious diseases and a variety of malignancies

  2. A second or third infection may coexist with cutaneous leishmaniasis

Leishmaniasis has many clinical manifestations and may appear similar to a wide variety of other conditions1, 2, 3 (Table I; Fig 1). Differentiation between conditions that mimic cutaneous leishmaniasis may require microbiologic, cytologic, and/or histologic evaluation.4 These include disorders that are infectious, malignant, or other disorders such

Diagnosis

Key points

  1. World travel has brought leishmaniasis to nonendemic regions

  2. The US Centers for Disease Control and Prevention accepts submissions for leishmaniasis testing worldwide

  3. Diagnosis may also be made via polymerase chain reaction studies, serologic assays, isoenzyme analysis, monoclonal antibody analysis RMPI media, and NNN media

An increase in international travel has brought leishmaniasis to nonendemic regions, where it often creates diagnostic dilemmas. A detailed history, including that of travel in

Histopathology

Key points

  1. Cutaneous leishmaniasis may feature amastigotes, a polycellular infiltrate, and/or granuloma formation

  2. Mucocutaneous leishmaniasis has 4 stages on histopathology: edematous, granulomatous, proliferative, and granulomatous necrotizing

  3. Chronic ulcers have fewer amastigotes compared to newer ones

  4. Diagnostic sensitivity is only about 60% in cases of Old World cutaneous leishmaniasis

  5. Amastigotes, known as Leishman–Donovan bodies, may sometimes be evident within macrophages

Histologic examination is an

Immunoprophylaxis

Key points

  1. Leishmania evades the immune system by inhibiting phagolysosome biogenesis

  2. Intentional infection on unexposed skin may prevent disfiguring facial lesions

  3. Live organism vaccination is still practiced in rural areas and has been a formal program in a few countries

  4. Killed parasite vaccines are not effective in leishmaniasis prevention

Leishmania is known to have many virulence factors enhancing infection and its spread. Metalloprotease GP63 is a highly active protease produced by Leishmania that

Treatment

Key points

  1. Systemic treatment is indicated if the lesions are large, multiple, affect the joints, hands, or feet, or the patient is immunosuppressed

  2. Intralesional antimonial drugs are less toxic than systemic therapy

  3. Liposomal amphotericin B is used in the developed world because it reduces hospitalization stays

  4. Sensitivity to treatment varies by nation and region

The numerous local and systemic treatments available for leishmaniasis are indicative of the difficulty in finding a successful remedy (Table VI).

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    Funding sources: None.

    Conflicts of interest: None declared.

    Date of release: December 2015

    Expiration date: December 2018

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