Leishmaniasis
FAQs for Health Care Providers
Cutaneous Leishmaniasis (CL) Risk, Diagnosis, and Treatment in Afghan Evacuees
Leishmaniasis (LM) is a protozoal parasitic infection of the genus Leishmania and is transmitted by sandflies. There are more than 20 species causing three clinical syndromes: cutaneous, mucosal and visceral leishmaniasis.
Have there been confirmed cases in the Afghan evacuees? Yes (cutaneous)
Found in ~90 tropical, subtropical and southern European countries. “Old World” (Eastern Hemisphere) cutaneous LM is common in Afghanistan and is caused predominantly by L. tropica (zoonotic L. major LM occurs in some northern areas of the country). Kabul is currently the largest focus of anthroponotic CL in the world, with 10 out of 34 provinces having high prevalence. Conflict, migration and displacement have contributed to increasing numbers. There are over 200,000 cases per year documented and there is strong household clustering in Afghanistan. Living in upper floors of an apartment complex is known to have a protective effect. The prevalence increases up to 15 years of age after which it stays stable, presumably due to increasing immunity. Lesions and scarring, particularly on the face and exposed areas, can lead to severe social stigma.
When should I consider cutaneous leishmaniasis?
Clinical Presentation
CL is the most common form of leishmaniasis in Afghanistan, although mucocutaneous disease is rarely observed. Skin lesions usually develop weeks to months after exposure (although can occur years after exposure), and generally persist for months to more than a year. Lesions begin as papules and evolve to nodular plagues and then to ulcers. The typical ulcers have a raised border and central depression. The depression may be covered in a scab or crust. Although solitary lesions are most common, there may be more than one primary lesion (on the same or different parts of the body) and satellite lesions may develop. They may have nodular lymphangitis (sporotrichoid-like) spread. There may also be regional lymphadenopathy (occasionally bubonic).
CL should be suspected in any Afghan evacuee with a cutaneous ulcer or nodular skin lesion. In Afghanistan, a majority of lesions occur on the head and upper extremities. If one individual in a household has suspected or confirmed LM, others who have dwelt with that individual should be carefully examined.
Is leishmaniasis contagious?
No, although it is common to find more than one person/household with infection.
Are there special infectious disease precautions for leishmaniasis? No
How do I diagnose cutaneous leishmaniasis?
LM is diagnosed by detecting Leishmania parasites (or DNA) in tissue specimens by light-microscope examination of stained slides (by an expert), molecular methods or through specialized culture techniques. The CDC provides reference services and detailed instructions on diagnosis.
The clinical differential diagnosis is extensive for cutaneous lesions and includes infectious (e.g. impetigo, fungal and mycobacterial infections), inflammatory (e.g. cutaneous lupus, sarcoidosis), and neoplastic disorders (e.g. non-melanoma skin cancer). The incorrect diagnosis and treatment can cause harm.
What is the management of cutaneous leishmaniasis and should I treat acutely or empirically?
Treatment options for CL can range from observation to topical non-antimonial treatment (e.g. cryotherapy, heat treatments, imiquimod, photodynamic therapy) to intralesional antimonials (e.g. sodium stibogluconate, meglumine antimoniate) to non-antimonial systemic therapy (e.g. amphotericin B, mitefosine, pentamidine, azoles, or parmomycin).
Treatment should not be started until the diagnosis of CL is confirmed and should be individualized to the patient, taking into consideration age, location and number of skin lesions, risk of scarring, comorbidities including immunocompromise, and patient preference.
Secondary bacterial infection may occur. Treat with appropriate antimicrobials.
CL is a chronic infection that is not contagious. Diagnosis and treatment may be delayed until expert consultation is available and the patient is in a stable social situation allowing for follow-up upon resettlement.
Resources and References:
Clinical Images of CLM
Below: Representative pictures of anthroponotic cutaneous leishmaniasis (ACL) cases obtained from Kerman and Bam cities
(Karimi, T., et al. A long-lasting emerging epidemic of anthroponotic cutaneous leishmaniasis in southeastern Iran: population movement and peri-urban settlements as a major risk factor. Parasites Vectors 14, 122 (2021). https://doi.org/10.1186/s13071-021-04619-3)
Below: Representative images of leishmaniasis in children (Jones J, et al. Old world cutaneous leishmaniasis infection in children: a case series Arch Dis Childhood 2005;90:530-531. https://adc.bmj.com/content/90/5/530)
Contributors
Aliya Mahmoud
Alexia Knapp MD
William Stauffer MD
Leishmaniasis Afghanistan evacuees_sept 20 branded.pdf