American cutaneous leishmaniasis in U.S. travelers

Clinical Manifestation of Cutaneous Leishmaniasis Following a Mechanical Trauma

Unusual skin ulcers frequently represent a diagnostic challenge. When the most common disease entities such as arterial, venous or diabetic ulcers have been excluded, the question of further differential diagnoses and procedures arises. Other possible causes include chronic inflammatory diseases, neoplasia, self-inflicted wounds, primary infectious diseases and physical/chemical damage to the skin. To narrow down the differential diagnoses, a detailed history of the patient is essential, which also needs to include events further back in time.

Everything old is new again: a case series of pediatric cutaneous leishmaniasis in Portland, Maine

Leishmaniasis has varying clinical manifestations and treatment regimens, dependent on species and host. Old world leishmaniasis, found primarily in Africa and Asia, may be associated with visceral disease, while new world disease, primarily in Latin America, may be associated with mucocutaneous disease. We present a case series of pediatric African patients with New World cutaneous leishmaniasis. Data extraction was performed via chart review, of children with cutaneous leishmaniasis presenting to the pediatric infectious diseases clinic in Portland, ME. Biopsy specimens were sent to the federal center for disease control (CDC) for identification via polymerase chain reaction (PCR) and culture. Five cases of cutaneous leishmaniasis were diagnosed in pediatric patients (ages 1-17 years) in Maine during the study period. Leishmaniasis was not initially suspected; thus, time to diagnosis was 1-4 months, Two patients were diagnosed with Leishmania panamensis, one with Leishmania brasiliensis, one with Leishmania sp. and one with mixed infection (L. panamensis and Leishmania mexicana). One patient was managed with surgical excision only, one was observed off therapy, and three were treated with ketoconazole. This case series highlights the importance of a high index of suspicion in migrant patients. Detailed travel history and epidemiologic knowledge is essential to diagnosis, as patients may present with forms of illness not congruent with their country of origin.

Leishmaniasis in the United States: Emerging Issues in a Region of Low Endemicity

Leishmaniasis, a chronic and persistent intracellular protozoal infection caused by many different species within the genus Leishmania, is an unfamiliar disease to most North American providers. Clinical presentations may include asymptomatic and symptomatic visceral leishmaniasis (so-called Kala-azar), as well as cutaneous or mucosal disease. Although cutaneous leishmaniasis (caused by Leishmania mexicana in the United States) is endemic in some southwest states, other causes for concern include reactivation of imported visceral leishmaniasis remotely in time from the initial infection, and the possible long-term complications of chronic inflammation from asymptomatic infection. Climate change, the identification of competent vectors and reservoirs, a highly mobile populace, significant population groups with proven exposure history, HIV, and widespread use of immunosuppressive medications and organ transplant all create the potential for increased frequency of leishmaniasis in the U.S. Together, these factors could contribute to leishmaniasis emerging as a health threat in the U.S., including the possibility of sustained autochthonous spread of newly introduced visceral disease. We summarize recent data examining the epidemiology and major risk factors for acquisition of cutaneous and visceral leishmaniasis, with a special focus on implications for the United States, as well as discuss key emerging issues affecting the management of visceral leishmaniasis.

Semi-quantitative measurement of asymptomatic L. infantum infection and symptomatic visceral leishmaniasis in dogs using Dual-Path Platform® CVL

Infection with Leishmania causes diseases with variable presentation. The most severe form is visceral leishmaniasis (VL), caused by either L. donovani or L. infantum. Despite efforts to eliminate VL, to date, molecular detection in resource-poor settings have lacked the accuracy and rapidity that would enable widespread field use and the need for accurate, sensitive assays to detect asymptomatic Leishmania infection has become apparent. The domestic dog serves as the primary reservoir host of L. infantum. Study of this reservoir population provides an opportunity to evaluate the sensitivity and specificity of diagnostics for well-defined, symptomatic, canine visceral leishmaniasis (CVL) and asymptomatic L. infantum infection. Blood samples from an L. infantum-endemic population of US hunting dogs were evaluated with Dual-Path Platform (DPP®) CVL compared to those obtained via direct detection methods (culture- and Leishmania-specific quantitative polymerase chain reaction, qPCR) and immunofluorescence anti-Leishmania antibody test (IFAT). Statistically significant correlations were found between DPP® CVL development time and clinical status, culture status, circulating DNA levels, and IFAT titer. DPP® CVL results correlated with both clinical severity of disease and serological evidence of asymptomatic L. infantum infection. By precisely documenting the minimum time required for the development of a clear positive result in DPP® CVL, this test could be used in a rapid, semi-quantitative manner for the evaluation of asymptomatic and symptomatic CVL. Our results also indicate that a similar test could be used to improve our understanding of human VL.

Real-time PCR using FRET technology for Old World cutaneous leishmaniasis species differentiation

Background

Recently, there has been a re-emergence of cutaneous leishmaniasis in endemic countries and an increase in imported cases in non-endemic countries by travelers, workers, expatriates, immigrants, and military force personnel. Old World cutaneous leishmaniasis is caused primarily by Leishmania major, L. tropica and L. aethiopica. Despite their low sensitivity, diagnosis traditionally includes microscopic and histopathological examinations, and in vitro cultivation. Several conventional PCR techniques have been developed for species identification, which are time-consuming and labour-intensive. Real-time PCR using SYBR green dye, although provides rapid detection, may generate false positive signals. Therefore, a rapid and easy method such as a FRET-based real-time PCR would improve not only the turn-around time of diagnosing Old World cutaneous Leishmania species but will also increase its specificity and sensitivity.

Methods

A FRET-based real-time PCR assay which amplifies the cathepsin L-like cysteine protease B gene encoding a major Leishmania antigen was developed to differentiate L. major, L. tropica, and L. aethiopica in one single step using one set of primers and probes. Assay performance was tested on cutaneous and visceral strains of Leishmania parasite cultures and isolates of other protozoan parasites as well as human biopsy specimen.

Results

The assay readily differentiates between the three Old World cutaneous leishmaniasis species based on their melting curve characteristics. A single Tm at 55.2 ± 0.5 °C for L. aethiopica strains was distinguished from a single Tm at 57.4 ± 0.2 °C for L. major strains. A double curve with melting peaks at 66.6 ± 0.1 °C and 48.1 ± 0.5 °C or 55.8 ± 0.6 °C was observed for all L. tropica strains. The assay was further tested on biopsy specimens, which showed 100 % agreement with results obtained from isoenzyme electrophoresis and Sanger sequencing.

Conclusion

Currently, there are no published data on real-time PCR using FRET technology to differentiate between Old World cutaneous Leishmania species. In summary, our assay based on specific hybridization addresses the limitations of previous PCR technology and provides a single step, reliable method of species identification and rapid diagnostic applications.

Cutaneous and mucocutaneous leishmaniasis: Differential diagnosis, diagnosis, histopathology, and management

The diagnosis of leishmaniasis can be challenging because it mimics both infectious and malignant conditions. A misdiagnosis may lead to an unfavorable outcome. Using culture, histologic, and/or polymerase chain reaction study results, a diagnosis of leishmaniasis can be established and treatment initiated. Appropriate management requires an accurate diagnosis, which often includes identification of the specific etiologic species. Different endemic areas have varying sensitivities to the same medication, even within individual species. Species identification may be of practical value, because infections with select species have a substantial risk of visceral involvement. In addition, HIV and otherwise immunocompromised patients with leishmaniasis have a propensity for diffuse cutaneous leishmaniasis. For most New World Leishmania species, parenteral antimonial drugs remain the first line of therapy, while Old World species are easily treated with physical modalities. Historically, live organism vaccination has been used and is effective in preventing leishmaniasis, but results in an inoculation scar and an incubation period that may last for years. A more effective method of vaccination would be welcome.

Leishmaniasis in travelers: a literature review

Leishmaniasis is a vector-borne protozoan infection whose clinical spectrum ranges from asymptomatic infection to fatal visceral leishmaniasis. Over the last decades, an increase in imported leishmaniasis cases in developed, non-endemic countries, have been pointed-out from a review of the international literature. Among the possible causes are increasing international tourism, influx of immigrants from endemic regions and military operations. The main area for the acquisition of cutaneous leishmaniasis, especially for adventure travelers on long-term trips in highly-endemic forested areas, is represented from South America, whereas popular Mediterranean destinations are emerging as the main areas to acquire visceral variant. Leishmaniasis should be considered in the diagnostic assessment of patients presenting with a compatible clinical syndrome and a history of travel to an endemic area, even if this occurred several months or years before. Adventure travelers, researchers, military personnel, and other groups of travelers likely to be exposed to sand flies in endemic areas, should receive counseling regarding leishmaniasis and appropriate protective measures.

Local or systemic treatment for New World cutaneous leishmaniasis? Re-evaluating the evidence for the risk of mucosal leishmaniasis

This review addresses the question of whether the risk of developing mucosal leishmaniasis (ML) warrants systemic treatment in all patients with New World cutaneous leishmaniasis (CL) or whether local treatment might be an acceptable alternative. The risk of patients with New World CL developing ML after the initial infection has been the main argument for systemic treatment. However, this statement needs re-evaluation and consideration of all the available data. The putative benefit of preventing ML should outweigh the toxicity of systemic antileishmanial therapy. To assess the need for and risk of systemic treatment the following factors were reviewed: the incidence and prevalence of ML in endemic populations and in travellers; the severity of mucosal lesions; the efficacy of current options to treat ML; the toxicity and, to a lesser extent, the costs of systemic treatment; the risk of developing ML after local treatment; and the strengths and limitations of current estimates of the risk of developing ML in different situations. Local treatment might be considered as a valuable treatment option for travellers suffering from New World CL, provided that there are no risk factors for developing ML such as multiple lesions, big lesions (>4 cm(2)), localisation of the lesion on the head or neck, immunosuppression or acquisition of infection in the high Andean countries, notably Bolivia.

Tropical skin infections among Israeli travelers

Infectious skin disorders are common dermatologic illnesses in travelers. Knowledge of post-travel-related infectious skin disorders will allow for effective pre- and post-travel counseling. All cases of returning travelers seen in our center seeking care for infectious skin diseases were included in this study. For a comparison, data on returned travelers with non-infectious skin diseases and healthy travelers who had pre-travel consultations in our institution were also analyzed. Altogether, skin-related diagnosis was reported in 540 ill travelers, and among them, 286 (53%) had infectious skin diseases. Tropical skin infection was diagnosed in 64% of the infectious cases. Travelers returning from Latin America were significantly more ill with tropical skin infections than those traveling to Asia and Africa, The most common diagnoses were cutaneous leishmaniasis, myiasis, and cutaneous larva migrans. In conclusion, tropical skin infections are common among Israeli travelers, especially among those who visited Latin America.

A live Leishmania major vaccine containing CpG motifs induces the de novo generation of Th17 cells in C57BL/6 mice

Cutaneous leishmaniasis produces open sores that lead to scarring and disfiguration. We have reported that vaccination of C57BL/6 mice with live Leishmania major plus CpG DNA (Lm/CpG) prevents lesion development and provides long-term immunity. Our current study aims to characterize the components of the adaptive immune response that are unique to Lm/CpG. We find that this vaccine enhances the proliferation of CD4(+) Th17 cells, which contrasts with the highly polarized Th1 response caused by L. major alone; the Th17 response is dependent upon release of vaccine-induced IL-6. Neutralization of IFN-gamma and, in particular, IL-17 caused increased parasite burdens in Lm/CpG-vaccinated mice. IL-17R-deficient Lm/CpG-vaccinated mice develop lesions, and display decreased IL-17 and IFN-gamma, despite normal IL-12, production. Neutrophil accumulation is also decreased in the IL-17R-deficient Lm/CpG-vaccinated mice but Treg numbers are augmented. Our data demonstrate that activation of immune cells through CpG DNA, in the presence of live L. major, causes the specific induction of Th17 cells, which enhances the development of a protective cellular immunity against the parasite. Our study also demonstrates that vaccines combining live pathogens with immunomodulatory molecules may strikingly modify the natural immune response to infection in an alternative manner to that induced by killed or subunit vaccines.

Efficacy of glucantime in the treatment of Old World cutaneous leishmaniasis

BACKGROUND

Leishmaniasis is a parasitic disease caused by protozoa of the genus Leishmania. Depending on the parasite species and host response, the disease presents itself in different clinical forms. The cutaneous form of the disease is most common in the Old World. Pentavalent antimonials in the form of an injection represent the most widely used therapy for all clinical forms of the disease. As a result of reports on the development of resistance from various parts of the world, we thought it pertinent to determine its response in our region.

METHODS

Two hundred and seven military personnel with cutaneous leishmaniasis, caused by Leishmania major, were treated with glucantime according to the World Health Organization (WHO) recommended protocol. All patients were nonindigenous to the area and had moved from a nonendemic area to a highly endemic area.

RESULTS

Thirty-seven per cent of patients were cured within 15 days. The cure percentage reached 81% when 20 mg/kg/day was continued to 20 days. Twenty-five patients who failed to respond were subjected to a further course of glucantime injection. Sixteen responded by the 10th day of treatment, and the remaining nine were cured by completion of the second course, i.e. within 40 days. The drug was administered intramuscularly. The common side-effects noted were vertigo, headache, anorexia, temperature, and joint pain.

CONCLUSION

Glucantime is still effective against Old World cutaneous leishmaniasis when used in the doses recommended by WHO.

Dermatologic conditions of the ill returned traveler: an analysis from the GeoSentinel Surveillance Network

BACKGROUND

Skin disorders are common in travelers. Knowledge of the relative frequency of post-travel-related skin disorders, including their geographic and demographic risk factors, will allow for effective pre-travel counseling, as well as improved post-travel diagnosis and therapeutic intervention.

METHODS

We performed a retrospective study using anonymous patient demographic, clinical, and travel-related data from the GeoSentinel Surveillance Network clinics from January 1997 through February 2006. The characteristics of these travelers and their itineraries were analyzed using SAS 9.0 statistical software.

RESULTS

A skin-related diagnosis was reported for 4594 patients (18% of all patients seen in a GeoSentinel clinic after travel). The most common skin-related diagnoses were cutaneous larva migrans (CLM), insect bites including superinfected bites, skin abscess, and allergic reaction (38% of all diagnoses). Arthropod-related skin diseases accounted for 31% of all skin diagnoses. Ill travelers who visited countries in the Caribbean experienced the highest proportionate morbidity due to dermatologic conditions. Pediatric travelers had significantly more dog bites and CLM and fewer insect bites compared with their adult counterparts; geriatric travelers had proportionately more spotted fever and cellulitis.

CONCLUSIONS

Clinicians seeing patients post-travel should be alert to classic travel-related skin diseases such as CLM as well as more mundane entities such as pyodermas and allergic reactions. To prevent and manage skin-related morbidity during travel, international travelers should avoid direct contact with sand, soil, and animals and carry a travel kit including insect repellent, topical antifungals, and corticosteroids and, in the case of extended and/or remote travel, an oral antibiotic with ample coverage for pyogenic organisms.

Special infectious disease risks of expatriates and long-term travelers in tropical countries. Part II: infections other than malaria

A wide range of viral, bacterial, and protozoal diseases pose risk to long-term tropical travelers. Risk varies geographically and with lifestyle. For some infections, risk increases with duration of stay, coming to resemble that of the local population. Risk management strategies include vaccination, chemoprophylaxis, avoidance measures, and screening, where appropriate. Vaccination against hepatitis A and B, typhoid, and rabies is recommended for all long-term travelers to (sub-)tropical areas. Lowering of the vaccination threshold for Japanese encephalitis is suggested. Meningococcal disease is rare in travelers, but vaccination is safe and acceptable. The efficacy of Bacillus Calmette-Guérin (BCG) is uncertain; immunological testing avoids BCG's confounding of tuberculin testing. Diarrhea is common, and self-treatment may be recommended. Sexually transmitted infections including human immunodeficiency virus (HIV) are serious risks; education, screening, and HIV postexposure prophylaxis following involuntary exposure are recommended. Many infections are chronic or asymptomatic, and appropriate screening is recommended on return or after prolonged exposure.

New world cutaneous leishmaniasis in travellers

As travel to Latin America has become increasingly common, cutaneous leishmaniasis is increasingly seen among returning travellers--eg, the number of observed cases has doubled in the Netherlands and tripled in the UK in the past decade. A surprisingly high proportion of cases were acquired in rural or jungle areas of the Amazon basin in Bolivia. The clinical manifestations range from ulcerative skin lesions (cutaneous leishmaniasis) to a destructive mucosal inflammation (mucocutaneous leishmaniasis), the latter usually being a complication of infection with Leishmania (Viannia) braziliensis. PCR is now the diagnostic method of choice, since it has a high sensitivity and gives a species-specific diagnosis, allowing species-specific treatment. Treatment of cutaneous leishmaniasis aims to prevent mucosal invasion, to accelerate the healing of the skin lesion(s), and to avoid disfiguring scars. Pentavalent antimonials drugs are still the drug of choice for many patients. However, a high rate of adverse events, length of treatment, and relapses in up to 25% of cases highlight the limitations of these drugs. Although only used in a small number of patients thus far, liposomal amphotericin B shows promising results. Further studies are needed to find efficacious and better-tolerated drugs for new world leishmaniasis.

Cutaneous leishmaniasis: an increasing threat for travellers

Analysis of the literature on cutaneous leishmaniasis in low-prevalence countries suggests an increase in imported cases that is attributable to the growing phenomenon of international tourism, migration and military operations in highly endemic regions. Cases of imported cutaneous leishmaniasis are often missed initially, but diagnosis can be made non-invasively by PCR using skin scrapings of lesions as starting material. Cutaneous leishmaniasis is an emerging threat for travellers and should be considered in all patients presenting with slow-to-heal ulcers.

Imported leishmaniasis in Germany 2001–2004: data of the SIMPID surveillance network

Leishmaniasis is a rare, non-notifiable disease in Germany. Epidemiological and clinical data, therefore, are scarce. Most infections seen in Germany are contracted outside the country. The German surveillance network for imported infectious diseases (Surveillance Importierter Infektionen in Deutschland, or SIPMID) recorded 42 cases of imported leishmaniasis (16 visceral, 23 cutaneous, and 3 mucocutaneous) from January 2001 to June 2004. Although most infections were acquired in European Mediterranean countries, the risk of infection was highest for travelers to Latin America. HIV coinfection was observed significantly more often in patients with visceral leishmaniasis than in patients with cutaneous/mucocutaneous leishmaniasis (31 vs. 4%, p=0.02). The median time to a definitive diagnosis was 85 days in cases of visceral leishmaniasis and 61 days in cases of cutaneous/mucocutaneous leishmaniasis, reflecting the unfamiliarity of German physicians with leishmanial infections. Visceral leishmaniasis was treated most frequently with amphotericin B, whereas cutaneous/mucocutaneous leishmaniasis was treated with a variety of local and systemic therapies. The findings presented here should serve to increase awareness as well as improve clinical management of leishmaniasis in Germany.

Cutaneous leishmaniasis in the returning traveler

Infection with protozoan parasites of the genus Leishmania leads to a wide variety of clinical disease syndromes called leishmaniasis, or more appropriately the leishmaniases. The three major clinical syndromes are cutaneous leishmaniasis, mucosal leishmaniasis, and visceral leishmaniasis. All three of these syndromes have been documented in returning travelers. This article focuses on cutaneous leishmaniasis with some comment on mucosal leishmaniasis.

Cutaneous leishmaniasis: current and future management

Leishmaniasis remains a major world health problem that continues to increase in incidence. This review considers epidemiology, clinical features, diagnosis and current treatment options. Recent developments in the treatment of simple cutaneous leishmaniasis are discussed followed by speculation about future therapies.

Localized cutaneous leishmaniasis imported into Paris: a review of 39 cases

BACKGROUND

Localized cutaneous leishmaniasis (LCL) is a common cause of dermatosis in travelers returning from the tropics. We describe the epidemiological, clinical, and biological aspects and therapeutic outcome of imported LCL.

METHODS

A retrospective study of all cases of LCL observed from 1992 to 2000 in our tropical disease unit. Diagnosis was based on direct examination of skin smear and/or culture with identification of subsequent subspecies.

RESULTS

Thirty-nine cases (25 males, 14 females; median age: 38 years) were included: 35 French travelers and four foreign immigrants; 15 cases were acquired in the Old World and 24 cases in the New World. The patients presented to our department with a median of 60 days after return. Thirteen patients had already consulted general practitioners, and the diagnosis was missed in five cases (38%). Five clusters were identified. The median number of skin lesions was two per patient. Diagnosis was established by direct microscopic examination in 36 cases (92%). Thirty-five patients were assessable for first-line treatment with antimonials (intramuscularly in 18, intralesionally in nine), intramuscular pentamidine isethionate or oral ketoconazole (four patients each). Twenty-five patients (71.4%) were cured. The remaining 10 patients were cured after one to three courses of other treatments. Overall adverse events occurred in 60% of the patients treated with antimonials and 37% of those treated with pentamidine.

CONCLUSION

Imported LCL is still unrecognized by Western physicians. Clusters may be observed in groups of travelers. The therapeutic outcome is impaired by numerous but minor side-effects.

Mucocutaneous leishmaniasis in a US citizen

Mucocutaneous leishmaniasis (MCL) is endemic to many areas of Central and South America. A case of MCL in a US citizen is reported here. An ulcer appeared on the patient's left hard palate, years after a working trip to Peru. Punch biopsies of the lesion were obtained, Leishmania promastigotes were isolated by culture and animal inoculation, and the patient was appropriately treated. As this case demonstrates, a patient's travel history is a key element in making a differential diagnosis of oral lesions.

Value of diagnostic techniques for cutaneous leishmaniasis

BACKGROUND

Traditional diagnostic tests, ie, smear, culture, and histopathology of a skin biopsy specimen, are not always conclusive in patients with a clinical diagnosis of cutaneous leishmaniasis (CL).

OBJECTIVE

Our purpose was to find out if a polymerase chain reaction (PCR) specific for Leishmania organisms might be more sensitive than the traditional diagnostic techniques, thereby decreasing the number of false-negative diagnoses.

METHODS

In a prospective study, smear, culture, and histopathology of skin biopsy specimens from 46 patients with a possible diagnosis of CL were compared with PCR specific for Leishmania. In addition, the Montenegro test as a measure of cellular immunity against the Leishmania parasite was performed. Proven CL was defined as a case in which at least 1 of the 3 traditional tests showed the presence of Leishmania parasites.

RESULTS

Of our 46 patients, 22 had leishmaniasis. Of the traditional tests, culture was the most sensitive but there were no statistically significant differences between the sensitivities of the various tests. PCR results were positive in all cases of proven leishmaniasis. Moreover, 3 patients with the clinical diagnosis of CL and negative findings on traditional tests had positive PCR results. Only 1 patient with a strong clinical suggestion of CL and positive Montenegro test results had negative PCR findings; this patient also had negative smear, culture, and histopathology results.

CONCLUSION

PCR appears to be the most sensitive single diagnostic test for CL.

Cutaneous leishmaniasis: an overview

Leishmaniasis is a major world health problem, which is increasing in incidence. In Northern Europe it is seen in travellers returning from endemic areas. The protozoa is transmitted by sandflies and may produce a variety of clinical syndromes varying from a simple ulcer to fatal systemic disease. This review considers the management of simple cutaneous leishmaniasis. Patients usually have a single ulcer that may heal spontaneously, requiring only topical, or no treatment at all. Lesions caused by Leishmania braziliensis may evolve into the mucocutaneous form, 'espundia', and should be treated with systemic antimony. Sodium stibogluconate 20mg/kg/day i.v. for 20 days is the appropriate first line treatment in these cases. Although it may cause transient bone marrow suppression, liver damage, a chemical pancreatitis, and disturbances in the electrocardiogram, it appears safe. The success of treatment should be assessed 6 weeks after it has been completed and patients should be followed up for 6 months.

Skin diseases of travelers

The astute clinician must consider common ailments that occur independently of travel and diagnoses resulting from exotic exposures. Most causes of travel-related skin conditions can be sorted by obtaining a careful history of the patients' pretravel medical conditions and preparations for the journey, and their activities and possible exposures during the trip. Skin disorders also may be grouped by description of the lesions, thereby directing the clinician's diagnostic efforts.

Travel health advice as recalled by 552 tourists to Peru

BACKGROUND

The process of health advice/education affects two groups of people, the health professionals who give the advice and the recipients who are offered this advice. The content of travel health advice has been investigated many times and has often been found to be of varying quality. However, little is known about how much advice clients recall. This study examined the travel health advice-seeking behavior of travelers to Peru, the degree of recall, and the amount of advice remembered.

METHOD

This descriptive study was based on questionnaires completed by 552 travelers to Peru while in Cusco. Information was collected on travel health-seeking behavior, sources of advice, tourists' degree of recall of information, and advice remembered.

RESULTS

Sixty-two percent (n=492) claimed to always seek health advice before traveling whereas 96% sought advice only for this specific trip. Most advice was obtained from travel clinics (37.7%), general practitioners (20.2%), or a guidebook (19.6%). Most tourists (60.4%) claimed to recall most of the advice; 23.4%, everything; 15.5%, some; and 0.6%, none (n=470). The number of items remembered ranges from 0 to 11.

CONCLUSION

Findings from the study indicated that the usefulness of travel health advice depends on the quality of information given and the recall of this advice. Both aspects need to be considered in order to be certain that the objective of travel health advice is met, which is the informed and safe travel health behavior. Further research is recommended.

Knowledge and behavior of tourists to Manu National Park, Peru, in relation to Leishmaniasis

BACKGROUND

Tourists have been infected with Leishmania braziliensis and the lack of appropriate travel information on the disease has been documented. The aim of this study was to describe the knowledge and behavior of tourists booked on a trip to Manu National Park in Peru in relation to leishmaniasis and its prevention.

METHODS

The clients of two tour operators in Cusco, Peru, represented the experimental and control group. The experimental group completed a questionnaire after the tour briefing the night before the trip and received the information leaflet. A second questionnaire was completed just before returning from the park. The clients in the control group did not receive the leaflet.

RESULTS

Three hundred and seventy-three questionnaire pairs were collected (173 experimental, 200 control). Only 24 (6%) of all participants claimed to have heard of leishmaniasis. Of the 92.5% of tourists who read the leaflet, 156 (97.5%) found it informative, although 50 (32.5%) wanted more information. It was suggested that the leaflet should be distributed by tour operators (56.9%), general practitioners/family doctors (49%), and travel agents (47.1%). There was no significant difference in the use of preventive measures between the groups. One-third of the experimental group claimed to have paid more attention to protection due to the information given in the leaflet.

CONCLUSIONS

There is generally a lack of knowledge on leishmaniasis with a great feeling of need for more and detailed information. Correct and complete information on leishmaniasis should be included in the health advice for travelers to endemic areas.

Leishmaniasis: recognition and management with a focus on the immunocompromised patient

Leishmaniasis is a protozoan disease whose clinical manifestations depend both on the infecting species of Leishmania and the immune response of the host. Transmission of the disease occurs by the bite of a sandfly infected with Leishmania parasites. Infection may be restricted to the skin in cutaneous leishmaniasis (CL), to the mucous membranes in mucosal leishmaniasis or spread internally in visceral leishmaniasis (VL). In the last 2 decades, leishmaniasis, especially VL, has been recognized as an opportunistic disease in immunocompromised patients, particularly those infected with HIV. Leishmaniasis is characterized by a spectrum of disease phenotypes that correspond to the strength of the host's cell-mediated immune response. Both susceptible and resistant phenotypes exist within human populations. Clinical cutaneous disease ranges from a few spontaneously-healing lesions, to diffuse external or internal disease, to severe mucous membrane involvement. Spontaneously-healing lesions are associated with positive antigen-specific T cell responsiveness, diffuse cutaneous and visceral disease with T cell non-responsiveness, and mucocutaneous disease with T cell hyperresponsiveness. Current research is focused on determining the extent to which this spectrum of host response is genetically determined. In endemic areas, diagnosis is often made on clinical grounds alone including: small number of lesions; on exposed areas; present for a number of months; resistant to all types of attempted treatments; and usually no pain or itching. Multiple diagnostic techniques are available. When evaluating treatment, the natural history of leishmaniasis must be considered. Lesions of CL heal spontaneously over 1 month to 3 years, while lesions of mucocutaneous and VL rarely, if ever, heal without treatment. Consequently, all the latter patients require treatment. Therapy is not always essential in localized CL, although the majority of such patients are treated. Patients with lesions on the face or other cosmetically important areas are treated to reduce the size of the resultant scar. In addition, the species of parasite should be identified so that infection with Leishmania braziliensis and Leishmania panamensis can be treated to reduce the risk of development of mucocutaneous disease. Treating patients with Leishmania and HIV co-infection requires close monitoring for effectiveness of treatment, especially because of the high relapse rates. Proven treatments include: antimonials, pentamidine, amphotericin B, interferon with antimony. Treatments where current clinical experience is too limited include: allopurinol, ketoconazole, itraconazole, immunotherapy, rifampin, dapsone, localized heat, paromomycin ointment and cryotherapy. Investigational treatments include: WR6026, liposomal amphotericin and miltefosine. In addition, vaccines for leishmaniasis are being investigated in clinical trials.

Leishmaniasis as an emerging infection

Leishmaniasis is a protozoan disease whose diverse clinical manifestations are dependent both on the infecting species of Leishmania and the immune response of the host. Transmission of the disease occurs by the bite of a sand fly infected with Leishmania parasites. Infection may be restricted to the skin in cutaneous leishmaniasis, limited to the mucous membranes in mucosal leishmaniasis, or spread internally in visceral leishmaniasis or kala azar. The overall prevalence of leishmaniasis is 12 million cases worldwide, and the global yearly incidence of all clinical forms approaches 2 million new cases (World Health Organization WHO/ LEISH/200.42, Leishmania/HIV Co-Infection in Southwestern Europe 1990-98: Retrospective Analysis of 965 Cases, 2000). In the last two decades, leishmaniasis, especially visceral leishmaniasis, has been recognized as an opportunistic disease in the immunocompromised, particularly in patients infected with human immunodeficiency virus.

The management of cutaneous leishmaniasis from Belize

We report 20 patients who contracted cutaneous leishmaniasis in Central and South America, 18 of them in Belize. The diagnosis was confirmed by the polymerase chain reaction (PCR) in 79% of those tested; the corresponding figure for histology was 62%, touch smear 46%, and culture 11%. Results of PCR can be falsely positive, so treatment should not be based on PCR alone. Of the 20 cases 18 were healed 6 weeks after intravenous sodium stibogluconate 20 mg/kg per day for 20 days. We present a management protocol.

Cutaneous leishmaniasis following local trauma: a clinical pearl

Cutaneous leishmaniasis is acquired from the bite of an infected sand fly and can result in chronic skin lesions that develop within weeks to months after a bite. Local trauma has been implicated as a precipitating event in the development of skin lesions in patients who have been infected with Leishmania species. Here we report a case series and review the literature on patients who developed cutaneous leishmaniasis after local trauma, which may familiarize clinicians with this presentation.

Cutaneous leishmaniasis

Leishmaniasis is a major World health problem, which is increasing in incidence. In Northern Europe it is seen in travellers returning from endemic areas. The protozoa is transmitted by sandflies and may produce a variety of clinical syndromes varying from a simple ulcer to fatal systemic disease. This review considers the management of simple cutaneous leishmaniasis. Patients usually have a single ulcer which may heal spontaneously, requiring only topical, or no treatment at all. Lesions caused by Leishmania braziliensis may evolve into the mucocutaneous form, 'espundia', and should be treated with systemic antimony. Sodium stiboglucoante 20 mg/kg/day i. v. for 20 days is the appropriate first line treatment in these cases. Although it may cause transient bone marrow suppression, liver damage, a chemical pancreatitis, and disturbances in the electrocardiogram, it appears to be safe. The success of treatment should be assessed 6 weeks after it has been completed and patients should be followed up for 6 months.

Leishmaniasis

In 1903, Leishman and Donovan separately described the protozoan now called Leishmania donovani in splenic tissue from patients in India with the life-threatening disease now called visceral leishmaniasis. Almost a century later, many features of leishmaniasis and its major syndromes (ie, visceral, cutaneous, and mucosal) have remained the same; but also much has changed. As before, epidemics of this sandfly-borne disease occur periodically in India and elsewhere; but leishmaniasis has also emerged in new regions and settings, for example, as an AIDS-associated opportunistic infection. Diagnosis still typically relies on classic microbiological methods, but molecular-based approaches are being tested. Pentavalent antimony compounds have been the mainstay of antileishmanial therapy for half a century, but lipid formulations of amphotericin B (though expensive and administered parenterally) represent a major advance for treating visceral leishmaniasis. A pressing need is for the technological advances in the understanding of the immune response to leishmania and the pathogenesis of leishmaniasis to be translated into field-applicable and affordable methods for diagnosis, treatment, and prevention of this disease.

Skin problems in the traveler

Skin lesions are common in travelers and include a mix of mundane dermatologic problems and rare diseases acquired only in remote or tropical regions. The morphology, distribution, and progression of the lesions are useful in assessing possible causes. Early in the evaluation it is important to determine whether the patient might have a process that is rapidly progressive, treatable, or transmissible. In addition to routine laboratory studies, biopsy and serologic tests are often necessary to confirm a specific diagnosis.

Infectious considerations in the world traveler

Travel-associated dermatoses are among the six most frequent medical problems encountered by international travelers. Skin disorders caused by parasites previously confined to the tropics are seen with increasing frequency by physicians in nonendemic areas. Cutaneous manifestations may provide important clues to the underlying infection. This article describes the epidemiology, assessment, and management of important parasitoses with cutaneous involvement.

Travel medicine problems encountered in emergency departments

This article reviews some common illnesses and conditions that prompt traveling patients to seek medical care in the emergency department in the United States. It also presents an emergency department approach to the initial diagnosis and treatment of travelers who are experiencing adverse side effects from pretravel immunizations and returned travelers who fear unusual, serious or exotic conditions and want immediate medical attention.

Leishmaniasis

Leishmaniasis is a protozoan disease whose diverse clinical manifestations are dependent both on the infecting species of Leishmania and on the immune response of the host. Transmission of the disease occurs through the bite of a sand fly infected with Leishmania parasites. Infection may be restricted to the skin in cutaneous leishmaniasis, limited to the mucous membranes in mucosal leishmaniasis, or spread throughout the reticuloendothelial system in visceral leishmaniasis or kala azar. Three rare clinical variants of cutaneous leishmaniasis include diffuse cutaneous leishmaniasis, leishmaniasis recidivans, and post-kala-azar dermal leishmaniasis.