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Synonyms: tropical sore, oriental sore, Baghdad sore, bouton d’Orient, Delhi boil,
aleppo boil, Chiclero ulcer.
Leishmaniasis is a vector-borne disease caused by obligate intramacrophage protozoa
that belong to genus Leishmania. Twenty-one species of Leishmania can infect
humans. The disease is endemic in tropical, subtropical, and southern European
countries, including Central and South america, asia, the Middle East, the
Mediterranean, and East and North africa. animal reservoir hosts include rodents,
bats, wolves, and foxes. Bites of ♀ sandflies transmit the parasite to humans.
Cutaneous leishmaniasis is the commonest type of leishmaniasis. Presentation is
determined by infectivity and virulence of the parasite and the host response—some
species induce a brisk inflammatory response, while others produce a more indolent
disease.

What should I look for?
• A history of travel to an endemic region: the average incubation time is about 2
months, but cutaneous leishmaniasis may not present for more than a year after the
sandfly bite.
• A history of sandfly bites (patients may not be aware of bites).
• Lesions on nocturnally exposed skin: face, neck, arms.
• One or more painless brownish nodules that may resemble bites, but usually do not
itch, and slowly enlarge into plaques or warty lesions (Old World disease), or boil-
like erythematous nodules that crust centrally and ulcerate in 1–3 months (New World
disease). Ulcers may expand to a diameter of 3–6cm.
• Satellite nodules may develop around the 1° nodule. Nodules may spread along
lymphatics (‘sporotrichoid spread’).
• Other members of the family may also have lesions, suggesting that the infection
was acquired by bites at the same time.

What should I do?
• Take one or two full-thickness 4mm punch skin biopsies from the raised edge of a
lesion or nodule for histological examination. histology is granulomatous, but, even
with a Giemsa stain, amastigote parasites may be difficult to find. Parasite DNA can
be detected in lesional material by PCR, replacing culture in many centres.
• Make a smear from slit skin scrape, tissue, or aspirate. Parasites are easier to find in
a smear than a biopsy.
• Culture material: first you will need to obtain the culture medium.
• Serology: usually unhelpful, because the antibody levels are low.
• Discuss management with an expert. Most lesions will heal without treatment in
3–18 months but leave a depressed scar which may be very disfiguring. patients with
New World leishmaniasis are at risk of developing mucosal disease. Intralesional, IM,
or IV pentavalent antimony (sodium stibogluconate) is still the mainstay of treatment.

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