A 47-year-old woman with no history of disease, had been treated unsuccessfully for several months for a chronic scab-covered ulcer on the skin of her neck, the cause of which had not been established.
In June 2023, the patient had been planning a holiday with her family in Bolivia and Peru and had had a travel medicine consultation and had received several vaccinations before the trip. During her 3-week trip in July, she had no health problems and mentioned only a few stings by unknown insects. She had spent most of her time in high mountain and jungle areas.
In September 2023, the patient developed neck pain on the left side, and after a few days, she noticed a tender inflammatory infiltrate with a centrally located ulcer covered with scab and slightly enlarged regional lymph nodes (Figure 1 A). The patient had several consultations with a dermatologist, an internist, and a surgeon who recommended therapies with 7 days of erythromycin, followed by oral clindamycin, anti-allergic drugs, and topical corticosteroids, with no clinical improvement.
For the above reasons, in January 2024, the patient was hospitalized in the Dermatology Department. Based on histopathological examination of a sample from the edges of the ulcer, the suspected lymphoma, mycosis fungoides, or actinomycosis were not confirmed, and unfortunately, no definitive diagnosis was made.
In February 2024, during a visit to the travel medicine office for the continuation of hepatitis A+ B vaccination, the infectious disease physician noticed a persistent skin lesion on the skin of the neck and referred the patient to the First Department of Infectious Diseases with a suspicion of tularaemia or cutaneous leishmaniasis, given the possibility of an insect sting during the trip to South America she had taken 9 months earlier.
During one-day hospitalisation, baseline peripheral blood tests were performed, and no abnormalities were found; blood was drawn for serology for tularaemia. The scab was removed, and a swab was taken from the bottom of the ulcer for PCR testing for tularaemia and leishmaniasis (Figure 1 B). Pending the ordered test results, the patient was discharged with the recommendation only to continue disinfection of the wound. After a week, a positive PCR result was obtained for Leishmania brasiliensis guyanensis. Testing for tularaemia was negative.
Based on recommendations for the treatment of leishmaniasis and the drugs available in Poland, the patient was offered treatment with oral fluconazole for four weeks at a dose of 100 mg twice a day and topical cryotherapy treatments.
Three cryotherapy treatments for the persistent skin lesion were carried out at 14-day intervals at the Dermatology Outpatient Clinic. After the treatments, a temporary deterioration of the local condition was observed (Figure 1 C), followed by a clinical improvement. The therapy resulted in the healing of the lesion with a scar (Figure 1 D). The patient felt good throughout the treatment period. Unrecognised or late-diagnosed cutaneous leishmaniasis can be complicated by the spread of lesions leaving disfiguring scars; however, in this patient, no lesions were observed on other parts of the body.
Leishmaniasis is a chronic protozoan infection occurring in humans and several animal species and is caused by more than 20 species of Leishmania [1]. Infection occurs via flies of the genera Phlebotomus and Lutzomyia [1]. There are four main clinical forms of the disease: cutaneous, mucocutaneous, diffuse cutaneous, and visceral; the occurrence of a particular form in an infected person depends on the immune status of the host and the species of Leishmania that caused the infection [1].
The disease is found worldwide, while it is endemic in more than 90 countries in Latin America, the Mediterranean basin, and parts of Africa and Asia [1, 2]. Approximately 700,000 to 1.2 million people contract the cutaneous form of leishmaniasis annually [3]. Statistics on the incidence of leishmaniasis in Poland are not kept as this is not a notifiable disease [4]. Few reports are available in the literature, and those that exist report isolated cases or small series diagnosed in Polish centres [5–9].
Cutaneous leishmaniasis and the mucocutaneous form are the most common forms of the disease [1]. Most often, cutaneous leishmania manifests as a small, well-demarcated papule (at the site of microbial penetration), which may enlarge to form a nodule or plaque that may then ulcerate or form papillary hyperplasia [1]. Numerous variants of cutaneous leishmaniasis have been described: zoonotic, anthroponotic, recurrent, lupoid, plaque-like, sporotrichosis, pustular, lichen-like, eczematous, sarcoid-like, rosaceous, papulopustular, papillary, disseminated, or diffuse (the latter sometimes distinguished as a separate clinical form) [1, 2]. Most often, the cutaneous form resolves spontaneously after a few months with the formation of a scar; nevertheless, the infection can progress to a chronic or disseminated form [1].
Diagnosis, in addition to the history and consideration of the clinical picture, which is sometimes very diverse and atypical, includes a histopathological examination of a biopsy from the ulcer margin (stained, for example, by the Giemsa method), culture from a swab from the bottom of the ulcer (e.g., on NNM medium), or PCR examination of a swab from the bottom of the lesion [1, 6]. Occasionally, serologic diagnosis is used, but it is mainly applicable in the visceral and sometimes mucocutaneous form [1, 6].
The differential diagnosis of the cutaneous form of leishmaniasis is broad and includes reactions from arthropod bites, tuberculosis, tularaemia, leprosy, mycobacteriosis, sarcoidosis, syphilis, mycosis fungoides, or basal cell carcinoma [1, 6].
First-line treatment is sodium antimony gluconate (20 mg/kg parenteral for 20 days or intralesional) and miltefosine (50 mg 2–3 times daily for 28 days) [1, 6]. These drugs are not available in Poland. Alternative therapies include topical paromomycin 15% with 0.5% gentamicin or 12% MBCL, parenteral pentamidine, fluconazole (200 mg daily or 6–8 mg/kg for 6 weeks), and sometimes ketoconazole, itraconazole, amphotericin B, or dapsone [1, 6]. Cryotherapy is also used, either in monotherapy or in combination with systemic treatment [7, 10].
Currently, in Poland, leishmaniasis is a disease affecting people returning from countries with a warmer climate, but the fact that native cases have been found in Germany, Austria, and Hungary and the observed climate warming increasing the range of Leishmania spp. vectors make it likely that the disease will become endemic in Poland, so it is necessary to know its symptomatology, and methods of its diagnosis and treatment [11, 12].
