Cutaneous leishmaniasis contracted in French Guiana: A case report

Yann A. Meunier

摘要

We report the case of a 19 year old male who presented with an ulcerated skin lesion on his right forearm. Given his past history and the clinical picture, the diagnosis of cutaneous leishmaniasis was established. An oral antibiotic therapy was prescribed and cure was achieved within one month. Case Report Mr. P. R. was a 19 year old single male, mechanic, without any children and with no significant past medical or surgical history. He came to consultation for an “ulcerated skin lesion on the anterior side of his right forearm”.The history of his disease started two months earlier in French Guiana where he was posted during his national military service. It manifested itself with an erythematous, non pruriginous papule at the above mention body site. It grew progressively and became gradually ulcerated, covered with a crust cover while oozing purulent material. Moreover, the patient noticed enlarged lymph nodes along the path of lymphatic drainage of the lesion area. The lymph nodes were hypertrophied, like threaded beads, mobile, painless and without lymphangitis trails. Mr. P. R. remained afebrile at all times. In his past, he mentioned that in the previous months he had traveled upstream the Moroni River with his regiment a few times. On these occasions, he had lived in the Amazonian jungle for several days. On one these trips he had captured a three-toed sloth which he had tamed and brought back home. The biological check-up was negative. In particular the search for leishmaniae by needle aspiration under the crust after an antibiotic treatment remained unproductive. The leishmaniais serology did not evidence any specific antibodies. His pet was tested and harbored Leishmania tropica. The diagnosis of leishmaniasis was made based on the clinical picture and the epidemiology. The following treatment was given: Cloxacillin 500mg QID for 10 days with daily local antiseptic care. The lesion dried up gradually, the crust fell and the adenopathy regressed completely. One month later a scar could be observed with an elastic skin lightly shiny and salmon pink in color. Discussion The clinical picture presented by the patient is typical of cutaneous leishmaniasis found in French Guiana 1 (please see ulcer picture example below). The differential diagnosis includes sporotrichosis particularly because of the lymphadenopathy 2 . Contamination occurs through the bite of an infested phlebotomus mosquito 3 (sand fly). In this case, it is very likely that it took place during the stays in the Amazonian forest. Indeed, the mosquito size (2-3mm) enables it to fly through net holes 4,5 . Cutaneous leishmaniasis can be found throughout the world, distributed in vast foci: The dry form around the Mediterranean basin, in the Middle-east and in East Africa and the moist form in West Africa, Central and South America 6 . The incubation period varies from 2 to 4 months, but may be longer 7 . The parasitic search in the dermal oozing rarely isolates the leishmaniae, even after an antibiotic treatment 8 . A biopsy of the lesion edge has better yield but it leave an additional scar. To complete the parasitic investigation, one must place the sample in a NNN culture medium and inoculate a fraction into a hamster 9 . Leishmaniasis has various reservoir animals such as rodents and three-toed sloth in French Guiana 10 . The Montenegro intradermal reaction performed with leishmanial antigen has relative value because it remains positive indefineltly 11 . The serology is not vey useful for the diagnosis of cutaneous leishmaniasis because it comes back negative most of the time, particularly in old world leishmaniasis. The prognosis is always favorable with spontaneous healing 12 . Treatment rests mainly on (1) Oral antibiotic therapy to clean bacterial secondary infections, which are very common and (2) Local antiseptic care with the same purpose 13 . When the lesion is on the face, one can use intradermal injections of antimonials around the ulceration t

机译：我们报告了一名19岁男性右前臂皮肤溃疡的病例。考虑到他的过去历史和临床表现，确定了皮肤利什曼病的诊断。开出了口服抗生素疗法，并在一个月内治愈。病例报告P. R.先生是一名19岁的单身男性，技工，没有任何孩子，也没有明显的医学或手术史。他因“右前臂前侧皮肤溃疡性病变”而接受咨询。他的病史始于两个月前的法属圭亚那，在国家服兵役期间被派驻。在上述身体部位表现为红斑，非瘙痒性丘疹。它逐渐生长并逐渐溃疡，在渗出脓性物质时被外壳覆盖。此外，患者注意到病变区域的淋巴引流路径上的淋巴结增大。淋巴结肥大，像线珠，活动，无痛，无淋巴管炎痕迹。 P. R.先生始终保持着低调。在他的过去，他提到在过去的几个月中，他与他的军团一起在莫罗尼河上游旅行了几次。在这些场合，他在亚马逊丛林中生活了几天。在这些旅行中，他捕获了一只三趾树懒，他已经驯服并将其带回了家。生物学检查为阴性。尤其是在抗生素治疗后通过在皮下进行针吸法寻找利什曼原虫仍然没有结果。利什曼原虫血清学没有发现任何特异性抗体。他的宠物经过了测试，并带有热带利什曼原虫。根据临床表现和流行病学对利什曼病进行诊断。给予以下治疗：每天使用局部抗菌护理的氯唑西林500mg QID持续10天。病变逐渐干dried，结皮脱落，腺病完全消退。一个月后，可以观察到疤痕，其弹性皮肤略带光泽，颜色为鲑鱼粉色。讨论患者提供的临床图片是法属圭亚那1中发现的典型皮肤利什曼病（请参见下面的溃疡图片示例）。鉴别诊断包括孢子虫病，特别是由于淋巴结肿大2。感染是通过被感染的phlebotomus蚊子3（沙蝇）叮咬而发生的。在这种情况下，很可能是在亚马逊森林逗留期间发生的。实际上，蚊子的大小（2-3毫米）使其能够通过网孔4,5飞翔。全世界都发现皮肤利什曼病，分布广泛：地中海盆地周围，中东和东非为干燥形式，西非，中美洲和南美洲为潮湿形式6。潜伏期从2到4个月不等，但可能会更长7。即使经过抗生素治疗，在皮肤渗液中的寄生搜索也很少分离出利什曼原虫。病变边缘的活检具有更好的良率，但会留下额外的疤痕。为了完成寄生虫调查，必须将样品放入NNN培养基中，并将一部分接种到仓鼠中9。利什曼病在法属圭亚那10有许多储水动物，例如啮齿动物和三趾树懒。与利什曼抗原进行的黑山皮内反应具有相对价值，因为它不确定地保持阳性11。血清学检查对于皮肤利什曼病的诊断没有帮助，因为它在大多数情况下呈阴性，特别是在旧世界的利什曼病中。自发愈合的预后总是良好的12。治疗主要取决于（1）口服抗生素治疗，以清除继发性细菌感染，这很常见，并且（2）具有相同目的的局部消毒护理13。当病变位于面部时，可以在溃疡周围使用真皮内注射抗生素

Cutaneous leishmaniasis contracted in French Guiana: A case report

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