1. Cutaneous Leishmaniasis in OIF/OEF Soldiers
Leishmaniasis Working Group
July 2004

2. Introduction
Leishmaniasis is a parasitic disease transmitted by the bite of sand flies.
Found in parts of at least 88 countries including the Middle East
Three main forms of leishmaniasis
Cutaneous: involving the skin at the site of a sandfly bite
Visceral: involving liver, spleen, and bone marrow
Mucosal: involving mucous membranes of the mouth and nose after spread from a nearby cutaneous lesion (very rare)
Different species of Leishmania cause different forms of disease

3. Cutaneous Leishmaniasis (CL)
In Iraq & Kuwait, L. major is the most common species
L. major causes skin infection
Approx. 1.5 million new cases of cutaneous leishmaniasis (CL) in the world each year
>500 cases of CL from L. major from OIF by Spring 2004! (only few cases from OEF)

4. Endemic Areas for Leishmaniasis
Highlighted areas are parts of the world where leishmaniasis has been reported.
Taken from British Medical Journal :378
BMJ 2003;326:378

5. Cutaneous Leishmaniasis (CL)
Sore is commonly called the “Baghdad boil”
No OIF CL has disseminated to visceral
All Leishmaniasis is highly preventable!
Data on leishmaniasis is based on voluntary reporting by countries so true incidence may be higher in countries that are not likely to report.
Numbers of cases in Iraq come from recent Promed messages (authors Desjeux and Deresinki)

6. “In some cities infection is so common and so inevitable that normal children are expected to have the disease soon after they begin playing outdoors, and visitors seldom escape a sore as a souvenir. Since one attack gives immunity, Oriental sores appearing on an adult person in Baghdad brands him as a new arrival…”
Introduction to Parasitology, 1944

7. Prevention
Suppress the reservoir: dogs, rats, gerbils, other small mammals and rodents
Suppress the vector: Sandfly
Critical to preventing disease in stationary troop populations
Prevent sandfly bites: Personal Protective Measures
Most important at night
Sleeves down
Insect repellent w/ DEET
Permethrin treated uniforms
Permethrin treated bed nets
Sandflies bite dusk to dawn so personal protection is most important during these times.
Even light clothing covering skin is sufficient to prevent the bite of the sandfly.
DEET is the most effective insect repellent.
Sandflies are small enough to fly through bed netting unless it is treated with permethrin.

8. Life Cycle
1- Sandfly bites animal and ingests blood infected with Leishmania
2- Sandfly bites human and injects Leishmania into skin
Reservoir: Small animals – including dogs, rats, gerbils, sloths.
Vector: Sandflies which become infected by ingesting blood from these small animals. The sandfly is very small and does not make noise when it flies. They are most active at night (from dusk to dawn) and less active during the hottest part of the day. About 1/3 the size of a mosquito, they can fly through the mesh of mosquito nets unless the bed nets are treated with Permethrin. Their mouthparts are too small, however, to bite through clothing.
Lifecycle:
Leishmaniasis is spread to humans by the bite of some types of sand flies. Sand flies become infected by biting an infected animal (for example, a rodent or dog) or person. When the sandfly bites an infected animal it ingests blood (specifically white blood cells) infected with Leishmania. The Leishmania changes form inside the gut of the sandfly – from amastigote to promastigote.
At night, the sandflies slip through untreated bed nets or land on skin without repellent and bite. Leishmania from the gut of the sandfly are are injected into the skin of the human. In the human the Leishmania again change form – back to amastigote.
If another sandfly bites the infected human, the sandfly ingests blood infected with Leishmania, becomes infected, and flys off to infect another human or animal. The life cycle continues.
Leishmaniasis also can be spread by blood transfusions or contaminated needles.
4- Cycle continues when sandfly bites another human or animal reservoir
3- Another sandfly bites human and ingests blood infected with Leishmania

9. Photograph provided by COL Naomi Aronson

10. Photograph provided by COL Naomi Aronson

11. Cutaneous Leishmaniasis (CL)
Most common form
Characterized by one or more sores, papules or nodules
Sores can change in size and appearance over time
Often described as volcano-like with a raised edge and central crater
Sores are usually painless but can become painful if secondarily infected
Swollen lymph nodes may be present near the sores (e.g. axilla/epitrochlear if sores are on the arm or hand)
Some sores are covered by a scab or have not yet ulcerated so they may look like red raised plaques- sometimes with dry crust/scale

12. Cutaneous Leishmaniasis (CL)
Most sores develop within a few weeks of the sandfly bite, however they can appear up to months later
Sores of CL heal spontaneously in 2-12 months
Sores can leave significant scars and be disfiguring if they occur on the face

13. Small, raised lesion on trunk without significant oozing or scab.
Photograph provided by COL Naomi Aronson

14. Multiple lesions on arm with a variety of appearances.
Photograph provided by COL Naomi Aronson

15. Both lesions are leishmaniasis
Note the raised border and wet appearance of the sore on the back of the hand.
Sores over joints are very concerning as scarring with healing can lead to limited movement of joint.
Photograph provided by COL Charles Oster

16. Back of hand.
Note raised border and wet appearance. Patient has bacitracin ointment applied to lesion.
Photograph provided by COL Naomi Aronson

17. Upper Eyelid.
Note the dry, crusted/scabbed appearance which is different than previous sores shown.
Photograph provided by COL Naomi Aronson

18. Close up of another dry, crusted lesion with concentric surrounding scale. This is a typical appearance for Old World Leishmaniasis.
Photograph provided by COL Charles Oster

35. Cutaneous Leishmaniasis (CL) Diagnosis
Heightened awareness of individuals, small unit leaders, and medical personnel is critical
Nonhealing sores (4-6 weeks) after a trial of oral antibiotics should be referred for evaluation
Soldiers/deactivated personnel should tell their provider that they were in SW or Central Asia

36. Cutaneous Leishmaniasis (CL) Diagnostic Testing
Dermal scraping and smear is recommended if the presumptive diagnosis is CL, and should augmented by submission of tissue for Polymerase Chain Reaction ( PCR) -see attached info sheet & accompanying video.
On occasion, a deep scraping of a skin lesion can be sufficient when the tissue scraping is subjected to giemsa stain, Leishmania culture and/or PCR.

37. Diagnosis – Dermal Scraping & PCR Minimize blood & overlying keratin/crusted debris!

38. Cutaneous Leishmaniasis (CL) Diagnostic Testing
Punch biopsy with touch prep may be preferred for atypical lesions & if other disease processes are being considered (see attached info sheet).

39. Cutaneous Leishmaniasis (CL) Diagnostic Testing
Army pathologists interpret scrapings & any biopsies/touch preps via Giemsa stains.
Forward slides & PCR specimens to AFIP. (See AFIP web site re: CL & attached Army Pathology Consultant info paper). AFIP maintains registry.

40. Leishmania Diagnostic Laboratory (LDL) at WRAIR
MTFs and the AFIP maintain a close working relationship with the LDL
Tissue culture & PCR interpretation capability
POC LTC Pete Weina, CPT Eric Fleming, Mr. John Tally
DSN /9206/9487 FAX , com

41. Cutaneous Leishmaniasis (CL) Diagnosis
If a patient has lesions that were historically consistent with CL, but are now almost completely healed or re-epithelialized, no diagnostic testing may be needed at all.
Document such cases for tracking purposes as “clinically presumptive CL”

42. Cutaneous Leishmaniasis (CL) Treatment
Early recognition, testing, & treatment is critical for facial involvement, other exposed sites, & for those with rapidly enlarging or multiplying lesions

43. Cutaneous Leishmaniasis (CL) Treatment Options
- No Rx (self-resolving process)
- Paromomycin topical (not yet FDA approved)
- Cryotherapy ( localized freezing)
- ThermoMed (localized heat)
- Fluconazole -oral (off-label use, for L. major only )
- Pentostam (sodium stibogluconate) – IV for days

44. Cutaneous Leishmaniasis (CL) No Treatment (watchful waiting)
For lesions that are in the late resolution phase, with near complete re-epithelialization
For small (<nickel-sized/2cm) and few (<5) lesions, especially on concealed locations of the trunk & proximal extremities, a patient can elect no treatment after discussing other options with the provider

45. Cutaneous Leishmaniasis (CL) Paromomycin Topical Ointment Rx
Not currently FDA approved
Used extensively in other countries
For ulcerative lesions
AMEDD is studying this option

46. Cutaneous Leishmaniasis (CL) Cryotherapy Treatment
Cryotherapy (localized freezing) - liquid nitrogen
Only for those experienced in this technique
30 second freeze, 60 second thaw, repeat once
Extreme caution/avoid in darker-skinned patients

47. Cutaneous Leishmaniasis (CL) ThermoMed (localized heat Rx)
Battery-operated radiofrequency device
Generous local anesthesia - 2% lidocaine
30 second burst to sized grids
Site Rx with gentamicin or bacitracin oint. and non-stick dressing
Requires training by those experienced with device (see accompanying video)

48. Cutaneous Leishmaniasis (CL) Fluconazole Treatment
- Not FDA approved for CL
- L. major only!
- Use is off label per NEJM 2002;346:891
- Response might be slower than other treatments

49. Cutaneous Leishmaniasis (CL) Pentostam (antimonial sodium stibogluconate) Rx
Given under a special FDA approved protocol ONLY at Walter Reed Army Medical Center (WRAMC) & Brooke Army Medical Center (BAMC) ID services in the U.S.
WRAMC- DSN /6740/8684/8691/8696, com
BAMC- DSN /5554/0848, com
10-20 days of IV therapy
Consider for those with active facial, ear, hand, feet lesions, large (>3cm) or multiple (>5) lesions, over joints of hands,feet, elbows, or those who have failed other modalities (after 60 days)
Since L tropica is of more concern in the SWA theatre (because of potential visceralizing infection, rare mucocutaneous involvement, and chronic (recidivans) skin infection) , would not advocate use of azoles routinely as there is not data to support their use in L.tropica and speciation can not be reliably made using clinical appearance.
Mucocutaneous infection is treated with a longer treatment course (28 days)

50. Cutaneous Leishmaniasis (CL) Practical Considerations
Leishmaniasis - lifelong ban as blood donor
CL by L. major is not contagious (possible exception: very rare genital lesions - use condom)
Relapse may occur in healed sites 2-3 months after Rx, requiring re-evaluation

51. Cutaneous Leishmaniasis (CL) On-line Resources
Army Derm AKO website

52. Cutaneous Leishmaniasis (CL) Regional POC - Clinical Questions
ERMC MAJ Greg Dye
NARMC LTC Glenn Wortmann
SERMC MAJ Rob Willard
GPRMC COL David Dooley
WRMC COL Joe Morris
PRMC COL Susan Fraser
via AMEDD Outlook

53. Cutaneous Leismaniasis (CL) Pentostam Questions/Referrals
East of Mississippi:
WRAMC DSN /6740/8684/8691/8696, com
West of Mississippi:
BAMC DSN /5554/0848, com

54. Cutaneous Leishmaniasis (CL) Preventive Medicine/Reporting POC
ERMC COL Kent Bradley
NARMC COL Dallas Hack
SERMC LTC Edward Boland
GPRMC COL Forest Oliverson
WRMC COL Evelyn Bararaza
PRMC COL Glenn Wasserman
via AMEDD Outlook

55. Visceral Leishmaniasis (VL)
12 cases in ODS from L. tropica
2 cases thus far from OEF/ 1 from OIF
Fever, malaise, hepatospenomegaly, pancytopenia, hypergammaglobulinemia
Can cause serious illness – refer quickly!
Leishmaniasis is highly preventable!
Contact Army Infectious Disease specialist