Leishmaniasis recidiva cutis and its topical treatment in ecuador.

A seven-year-old girl presented to the Department of Tropical Medicine, Biomedical Research Center, Central University of Ecuador, with four small crusted papules in the periphery of a large central scar on her left cheek. A primary lesion had appeared a year before as a painless but itchy mosquito-bite-like papule that later ulcerated and healed without treatment in approximately six months. However, four months later four small papules appeared on the border of the scar (Panel A). She received intramuscular pentavalent antimonial (Glucantime) for 15 consecutive days, but the lesions showed no improvement. Skin smears taken from one of the crusted papules and stained with Diff-QuikTM solutions I-III (Seamens Healthcare Diagnostics Inc., Newark, DE, USA) showed abundant Leishmania amastigotes. The parasite was identified by polymerase chain reaction (PCR) as belonging to Leishmania (Viannia) guyanensis. Cutaneous leishmaniasis that relapses and manifests in small crusted or ulcerated papules is called lupoid, relapsing, or chronic cutaneous leishmaniasis in the Old World or leishmaniasis recidiva cutis (LRC) in the New World. Since this clinical form is a very rare case of American tegumentary leishmaniasis, it is worth imaging the unusual clinical presentations for the reference of physicians and researchers working in areas endemic for leishmaniasis and for physicians examining patients from tropical and subtropical regions [1]. The present patient and her parents consented to participate in this study.

Panel A (left). The four crusted papules in the periphery of an old healed lesion (scar) show characteristics of leishmaniasis recidiva cutis (LRC). Samples for smear and in FTA card for PCR were taken from the active crusted papules.

Panel B (right). The healed lesions after two months of applying the lotion show scars less pronounced than those left by the intramuscular treatment with Glucantime.

Because the patient had been treated before with intramuscular Glucantime injections and not cured, we administered a topical lotion comprised of Glucantime plus Merthiolate® (50% and 50% concentration). After two months of application the lesions healed as shown in Panel 2. A previous study done by our group applying this lotion with a lower concentration of Glucantime resulted in a marked improvement in 16 patients [2]. Searching for new alternatives of treatment for cutaneous leishmaniasis is mandatory since the recommended systemic injections of antimonials are toxic with poor compliance and not always available in endemic areas.