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By Philip R. Fischer, MD, DTM&H
Dr. Fischer is Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN.
Dr. Fischer reports no financial relationships relevant to this field of study.
SYNOPSIS: Cutaneous leishmaniasis is spreading as refugees move from Syria through Turkey into Europe and throughout the world. Aware clinicians can consider diagnostic testing when facing unusual skin lesions in refugees.
SOURCE: Hayani K, Dandashli A, Weisshaar E. Cutaneous leishmaniasis in Syria: Clinical features, current status, and the effects of war. Acta Derm Venereol 2015;95:62-66.
Cutaneous leishmaniasis is transmitted in nearly 100 countries and is especially common in some developing countries, including Syria. Concerned about war-induced changes in the epidemiology of infections in Syria, the investigators reviewed Syrian experience with cutaneous leishmaniasis.
Oral tradition includes stories of a Syrian “one year sore” with unusual cutaneous lesions. This condition was documented in the Middle Ages. More recently (in 1756), a British physician referred to the illness as Aleppo boil and Aleppo evil — named for the north Syrian city where the authors worked. With widespread insecticide use during the middle of the last century, cutaneous leishmaniasis became less common. The incidence, however, began to rise in recent decades when insecticide was not commonly used. The incidence has risen more than 10-fold during the past decade.
In Aleppo, Leishmania tropica accounts for most cutaneous leishmaniasis, and L. major is a more common cause in the suburbs of Damascus. Fat sand rats, gerbils, and dogs are the typical animal reservoirs, but human-to-human transmission occurs through phlebotomine sand flies without other animal involvement in some areas.
The clinical presentation varies with the parasite species involved and with the immune status of the patient, and the character of the skin lesions is quite variable. A reddish papule appears (presumably at the site of a sand fly bite), and nodules and ulcerations can develop. Lesions can appear to be poorly healing acne, unremitting lichenified eczema-like sores, papulo-vesicular spots, and ulcerating plaques. Within 12-18 months, the local infection usually resolves, but scars can be extensive and unsightly. Affected patients, even if the infection self-resolves, have higher anxiety and depression scores, lower body image satisfaction scores, and poor scores on quality-of-life testing.
The diagnosis is made by identifying Leishmania parasites in Geimsa-stained skin or, sometimes, by finding non-casseating granulomas in skin biopsies. Polymerase chain reaction (PCR) testing is not always available in endemic areas. Treatment depends on the extent of the disease. Topical treatment can be employed when there are three or fewer small lesions; intralesional injection of meglumine antimonate is effective. (NOTE: This treatment is not approved for use in the United States.) Larger, more numerous, and potentially more disfiguring lesions can be treated systemically with intramuscular meglumine antimonate or intravenous sodium stibogluconate for 2 to 3 weeks. In other areas with greater medication availability, meltifosine and liposomal amphotericin can be used.
A protest in March 2011 in southern Syria prompted a governmental reaction and widespread civil unrest. More than 200,000 people have died. The political situation has grown more complicated with the involvement of not just the government and rebels, but now also the Islamic State. Aleppo, formerly a thriving city of 2.5 million with 6000 doctors, is now said to be “a city in ruins.”1 Hundreds of health care professionals have died in the conflict, and it is said that 75% of health workers are part of the more than 4 million people leaving the country.1 Interestingly, the two authors of this paper who were from Aleppo now have addresses in Germany and the United Arab Emirates. The crisis has provoked increases not only in cutaneous leishmaniasis, but also polio, measles, and tuberculosis.1
Spreading to Lebanon and Turkey
As Syrians leave their homeland, they sometimes carry their germs with them. There have been dramatic increases in the number of cases of cutaneous leishmaniasis in southeastern Turkey.2 In Turkey, 69% of cutaneous leishmaniasis patients are Syrians living in tent cities. There, it is suggested that control efforts include improved housing, improved access to health care, and better vector control.2 While Lebanon previously only recorded 0-6 cases of leishmaniasis each year, there are now more than 1000.3
Risks in Europe and Beyond
As is clear from recent news reports, Syrian refuges don’t all stay in Turkey and Lebanon. There is a significant risk that cutaneous leishmaniasis will re-emerge in southern Europe where the natural vector of L. tropica already exists.4,5 Not just refugees, but also travelers can be affected by leishmaniasis and potentially serve as sources of transmission where the relevant sand flies reside. Most travel-related leishmaniasis has come from South America in recent decades,6 but that situation might change. While cutaneous leishmaniasis is more common in Brazil and Peru than in other countries of Latin America, most travel-associated leishmaniasis in the United States comes from Central America and Mexico.6
Clinical Suspicion Critical
Clinical suspicion of cutaneous leishmaniasis is the key to diagnosis. It is reported that infected Americans see six doctors and have multiple skin grafts prior to the correct diagnosis being considered.6 Skin samples are the first choice for seeking confirmation of the parasitic cause of otherwise unexplained skin lesions, but tissue PCR is more sensitive and is particularly useful when skin sample/biopsy histology is unrevealing.6 However, PCR can remain positive with lingering parasite antigens long after clinical cure; thus, PCR is not a good test to determine outcomes of treatment.6,7 Treatment is as noted in the Syrian report.