American cutaneous leishmaniasis: special features in diagnosis and therapy

History and clinical findings: Three weeks after returning from a trip to Guatemala, a 33-year-old man developed two ulcers with indurated edges on his right leg and painful lymph nodes in the right groin. His general condition was not impaired. Examinations: Histological examination revealed cellular infiltrates of the corium by lymphocytes and plasma cells, always accompanied by epitheloid cells and multinuclear giant cells. Special stainings were unable to detect pathogens but Leishmania brasiliensis was identified using PCR. The Leishmania culture remained negative. Therapy and course: After 7-day intravenous therapy with 20mg/kg/d pentostam (pentavalent antimonial compound), the patient developed gastrointestinal complaints, coupled with a marked elevation of transaminases. Therapy was discontinued until the transaminase values normalized, then continued in reduced dosage (12mg/kg body weight) for 23 days. The ulcers and lymphadenitis healed under this therapy. Conclusion: The diagnosis of American cutaneous Leishmaniosis may be complicated by the relative lack of pathogens in the lesions. PCR diagnosis are very helpful here. The therapy must be systemic owing to the danger of progression to mucocutaneous Leishmaniasis. The standard therapeutic pentostam has, however, a high rate of side effects and administration is exclusively intravenous.