Cutaneous leishmaniasis: A great imitator
Introduction
Leishmaniasis, caused by over 20 species of the genus Leishmania, is a neglected vector-borne parasitic infection that gives rise to a broad spectrum of diseases with protean manifestations.1,2 It is related to a variety of risk factors, such as poverty, malnutrition, migration, and poor housing conditions. Its incidence is on the rise in certain geographic areas of the world, including Syria, Turkey, and Jordan, due to war-associated migration and the resulting refugee crisis.[3], [4], [5], [6], [7], [8] Increased global travel also contributes to the growing problem of imported leishmaniasis.[9], [10], [11], [12] The most common form of leishmaniasis is cutaneous leishmaniasis (CL), which is estimated to affect 600,000 to 1 million new cases worldwide annually.13 Although not life-threatening, CL is an important entity to recognize and treat, because it can be associated with permanent scar formation, decreased quality of life, stigmatization, and long-term psychologic consequences.4,[14], [15], [16] Prevention and control requires a multifaceted approach including, but not limited to, vector control, disease surveillance, timely diagnosis, and appropriate treatment.13
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Historical perspective
Leishmaniasis has been documented throughout history.17,18 A molecular paleopathologic study demonstrated evidence of mitochondrial DNA of L. donovani in Egyptian mummies, suggesting that visceral leishmaniasis can be traced to ancient Egypt.18,19 The Oriental sore is believed to have been first described by Avicenna (980-1037) as Balkh sore.18,20,21 It has since been known by several names, such as Aleppo boil and Baghdad boil.17,18,20 The active inoculation of virulent Leishmania organisms
Microbiologic perspective
The main transmission of Leishmania species is anthroponotic or zoonotic, via phlebotomine sandflies, although human-to-human transmission by infected needles, transfusion, or congenital transmission have also been reported.[31], [32], [33], [34], [35], [36] The major sources of transmission are usually canines, rodents, or humans, depending on the species of parasite, the genus of vector, and geographic region.37 Approximately 90 different sandfly species belonging to Lutzomyia and Phlebotomus
Epidemiologic perspective
As of early 2019, leishmaniasis belonged to the list of 20 neglected tropical diseases according to the World Health Organization.41 Children suffer from the highest burden of leishmaniasis.42 Leishmania infections are seen in humans in nearly 90 countries located on every continent other than Australia and Antarctica. The parasite can adapt to a variety of ecologic conditions from rain forests to deserts. The disease is widely distributed among the tropical and temperate regions most of which
Clinical perspective
Three main clinical forms of leishmaniasis have been defined.13,50 The clinical presentation is dictated by the interplay of parameters related to the parasite (eg, species, virulence, and tropism) and the host immune response.4,5
Tumor or squamous cell carcinoma-like leishmaniasis
Tumor or squamous cell carcinoma-like form of CL lesions appear on the face, with a predilection to affect the nose and extremities (Figure 3). When they occur on the extremities, they should be differentiated from eccrine poroma, panniculitis, lymphoma, actinomycosis or mycetoma of the foot, and amelanotic melanoma. These lesions are often observed in pregnant women and in the elderly.96,101 The chronicity, absence of pain, and characteristic expansion of the lesions should be taken into
Erysipeloid leishmaniasis
The erysipeloid form of CL may be mistaken for a bacterial infection and is characterized by diffusely erythematous, infiltrated plaques over the cheeks and nose.106 These lesions are generally not ulcerated, cover the center of the face with varying degrees of scaling, and resemble erysipelas (Figure 4). The lesions are not uniformly flat, and the initial plaque area is more indurated or elevated. Lymphadenopathy or mucous membrane involvement is absent. Erysipeloid CL may differ from
Eczematous or psoriasiform leishmaniasis
Eczema-like, psoriasiform clinical variants of CL have been reported, necessitating a high index of suspicion for diagnosis.58,102 CL may appear as erythematous scaly lesions or hyperkeratotic plaques, mimicking psoriasis (Figure 6A, B, C). Patients with HIV tend to develop more psoriasiform CL lesions. An erythematous infiltrated lesion covered by scaling and crust usually forms at a single focus and spreads peripherally.95,[113], [114], [115], [116] Clinically, CL can manifest as acute
Discoid lupus erythematosuslike CL
Rarely, CL mimic discoid lupus erythematosus lesions and shows the butterfly distribution on the face. It can be misdiagnosed as discoid lupus erythematosus. Atrophic plaques, central scale and peripheral papules that are seen in LR can be misleading (Figure 8). Leishmanial granulomatous dermatitis is observed in the biopsy specimen instead of interface dermatitis.88,96
Acneiform CL
Acnelike lesions are rarely observed in patients with CL. They appear as multiple, symmetric, reddish-brown, monomorphic acneiform papules and nodules on the face (Figure 9). The disseminated form of CL may be misdiagnosed as an acneiform eruption. This clinical condition may be misdiagnosed as granulomatous rosacea or other granulomatous dermatitis.61,122
Sporotrichoid CL
Importantly, the sporotrichoid form of CL should be differentiated from other cutaneous infections with a sporotrichoid pattern, for example, sporotrichosis, atypical mycobacterial infections, nocardiosis, and cat scratch disease, to name a few.123 Sporotrichoid CL is caused by the dissemination of amastigotes to the subcutaneous tissues via the lymphatic system.113,124 Sporotrichoid patterns of New World CL from Brazil, most of which are due to Leishmania braziliensis, manifest with lesions on
Conclusions
The dermatologist plays a pivotal role toward the ultimate goal of eradication not only by recognizing and treating the clinical findings of the disease itself, but also by addressing the deep-rooted social implications (eg, collectively contributing to public health prevention measures and striving to eliminate social stigmatization). The World Health Organization has established multiple priority areas for research to combat leishmaniasis, emphasizing diagnostic techniques, new drug and
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