Cutaneous Leishmaniasis – A Case Series from Dresden

ID Design Press, Skopje, Republic of Macedonia Open Access Macedonian Journal of Medical Sciences. 2018 Jan 25; 6(1):89-92. Special Issue: Global Dermatology-2 https://doi.org/10.3889/oamjms.2018.028 eISSN: 1857-9655 Case Report Cutaneous Leishmaniasis – A Case Series from Dresden 1* 1 2 3,4 Uwe Wollina , André Koch , Claudio Guarneri , Georgi Tchernev , Torello Lotti 1 5 2 Städtisches Klinikum Dresden - Department of Dermatology and Allergology, Dresden, Germany; Department of Clinical Experimental Medicine, Unit of Dermatology, at the University of Messina (Italy), C/O A.O.U. “G. Martino”, via Consolare 3 Valeria, 1, 98125 Messina, Italy, Department of Dermatology, Venereology and Dermatologic Surgery, Medical Institute of 4 Ministry of Interior, Sofia, Bulgaria; Onkoderma Policlinic for Dermatology and Dermatologic Surgery, Sofia, Bulgaria; 5 University of Rome G. Marconi, Institute of Dermatology, Rome 00186, Italy Abstract Citation: Wollina U, Koch A, Guarneri C, Tchernev G, Lotti T. Cutaneous Leishmaniasis – A Case Series from Dresden Open Access Maced J Med Sci. 2018 Jan 25; 6(1):89-92. https://doi.org/10.3889/oamjms.2018.028 Keywords: Leishmaniasis; Protozoa; Cutaneous infection; Traveler’s diseases; Displaced people *Correspondence: Uwe Wollina. Stadtisches Klinikum Dresden - Department of Dermatology and Allergology, Dresden, Sachsen, Germany. E-mail: Leishmaniasis is world-wide one of the most common infectious disorders caused by protozoa. Due to the climate change, there is a risk of further spread of the disease to central and northern Europe. Another important issue is the high number of refugees from Syria since Syria is one of the hot spots of Old World leishmaniasis. We report on single-centre experience with leishmaniasis in the capital of Saxony, Dresden, during the years 2001 to 2017. We noted a substantial increase in the last five years. Once a very rare exotic disorder in Germany, cutaneous leishmaniasis has become a reality and physicians should be aware of it. A significant number of cases are from Syrian refugees; other cases had been acquired by tourists in the Mediterranean region! Received: 08-Aug-2017; Revised: 06-Sep-2017; Accepted: 07-Sep-2017; Online first: 10-Jan-2018 Copyright: © 2018 Uwe Wollina, André Koch, Claudio Guarneri, Georgi Tchernev, Torello Lotti. This is an openaccess article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0) Funding: This research did not receive any financial support Competing Interests: The authors have declared that no competing interests exist Introduction The climate change has the potential for distribution and epidemiology of skin diseases. In case of infectious dermatoses, climate may modulate the distribution of both, pathogens and vectors [1]. Leishmaniasis is a protozoal disease with cutaneous, mucocutaneous and visceral subtypes. World-wide, about two million people are affected. Pathogens are Trypanosoma-like Leishmania with the major subgenera Leishmania and Viannia. Around 20 species have been identified so far. Cutaneous leishmaniasis is classified into Old World- and New World- disease. Also, there is mucocutaneous and visceral leishmaniasis, also known as Kala-Azar [2]. The classical distribution of leishmaniasis is Central and South Americas, China, Sri Lanka, the Indian subcontinent, North, East, West and Central Africa, Middle East, and the Mediterranean. Transmission occurs by blood-sucking female insects of the genus Phlebotomus (Old World) and Lutzomyia (New World). Pathogen reservoir includes rodents, canine, feline, and humans. The incubation period may vary between some weeks and several months. The protozoa are located intracellular and modify the host response reactions immunologically [3]. Entomological investigations suggest changes in the geographical distribution of Leishmania vectors. An increased risk for vectors has been calculated for the European Atlantic coast, Austria, Germany, and Switzerland [4]. In Germany, there are two possible mosquito vectors, i.e. Phlebotomus (P.) mascittii and P. pernicious [5]. In Northern Italy, Ixodes ricinus had been identified as another possible vector since 7.5% of all tick bites had a positive polymerase chain reaction (PCR) for Leishmania (L.) infantum [6]. PCR plus sequencing and/ or multiple restriction enzyme _______________________________________________________________________________________________________________________________ Open Access Maced J Med Sci. 2018 Jan 25; 6(1):89-92. 89 Case Report _______________________________________________________________________________________________________________________________ digestions (RFLP) is now considered as gold standard in diagnosis [7]. We report on cutaneous leishmaniasis cases, diagnosed and treated at our department during the years 2001 - July 2017. complex. Eventually, L. infantum infection could be belayed. Other infections were acquired during holidays in Northern Italy and Crete, Greece. Patients and Methods This is a single-centre retrospective study using the patient files at the academic teaching hospital Dresden-Friedrichstadt from January 2001 to July 2017. All patients that could be identified by diagnosis of cutaneous leishmaniasis were included. Figure 1: Clinical presentations of Old World cutaneous leishmaniasis. (a) Plaques; (b) Atrophic plaques; (c) Plaque with elevated borders; (d) Ulcerated plaque with eschar; (e) Firm nodule; (f) Abscess-like nodule; (g) Erosive plaques; (h) Verrucous plaque; (i) Eczematous lesions Results We identified nine patients – 6 males and three females – with age between 1.5 years and 33 years. Five patients were refugees from Aleppo, Syria (Table 1). Table 1: Cutaneous leishmaniasis remission; CR, complete remission) 2001-17 (PR, partial We used pentavalent antimonials (Glucantime) (n = 5), meglumine stibnite (n = 1), azole derivates (n = 2) or paromomycin ointment (n = 1) to treat our patients. Eight patients achieved a complete remission (CR), one achieved a partial remission (PR). In the latter two cases, treatment is continued. Treatment was well tolerated. To reduce the injectionassociated pain, topical lidocaine/prilocaine ointment (EMLA® cream) was applied. We observed single delayed oedema after the second injection of glucantime on the cheek. With systemic corticosteroids, oedema disappeared within three days. Cutaneous leishmaniasis healed leaving scars (n = 7) and/or post-inflammatory hyperpigmentation (n = 4). Discussion All cases were identified since 2013; there was not a single case before. The lesions developed up to 6 months before a diagnosis was confirmed. Major differential diagnoses were pyoderma and infected insect bites. The diagnosis was confirmed by histologic proof of intracellular amastigotes in eosinhematoxylin or Giemsa stains. Four cases occurred in a single family. Here, we decided to confirm c (...truncated)