Multiple ulcerated nodules on the legs

presented by

Reuven Sobel, M.D.

Kibbutz Revivim, Israel

October 29, 2009

Abstract 50-year-old man with cutaneous leishmaniasis.
50-year-old man
2 months
Lower legs

A 50-year-old man, in good general health on no chronic meds but with history of mild hypertension, occasional asthma and multiple drug allergies.

FIve months ago, he was exposed to sandflies at a construction site and two months ago about 17 lesions developed on his lower legs and feet, some  of them 5-6 cm in diameter and partially ulcerated, one on his left leg with an area of lymphangitis. There has been no confirmed secondary infection or fever.    

Physical Examination

He has 17 lesions on his lower legs, 5-6 cm in diameter and partially ulcerated, rather large but painless, none with confirmed secondary infection


Laboratory Data

PCR pending




Cutaneous Leishmaniasis

Reason for presentation

He was started on an antimony compound (Pentosan), stopped because of an abrupt rise in serum amylase.  He is not receiving any topical therapy but the lesions are covered with mucopirin and bandaged.

As things stand now, he has been told that he should have amphotericin B lysosomal: no other systemic ( eg conazoles) or topical ( eg imiquimoid, cryotherapy, heat therapy, paromycin, intralesional antimony etc)  have been discussed.

It seems to me the indications for treatment are just the ugliness (which doesn't concern him that much) of the larger lesions and the danger of secondary infection.  Although, I have the impression from the literature (weak as it is) that topical therapy alone would not be enough, it is not clear to me that systemic therapy is essential given the possibility of adverse effects and the expense.

The dilemma seems to be how far to go in treating an ugly but self-limited asymptomatic skin problem.

  1. Suggestions for topical therapy other than paromycin and for systemic therapy other than antimony compounds.  
  2. Can lysosomal amphotericin B be justified?



cutaneous leishmaniasis

Comments from Faculty and Members

Omid Zargari MD, Consultant Dermatologist, Booali Medical Group, Rasht, Iran on 29 October 2009

Our usual therapy is antimonials, but if the ugliness is not a problem for the patient, the best remedy would be no-remedy. The Persian word for Leishman is "Salak" which means a disease that lasts for about one year to heal. In the southern parts of Iran there are a lot of herbal medicines for Salak. one of them is "Shiraz ointment" that seems to work, but I think it is not available in your promised land of Israel. The other option might be parmomycin ointment, not very effective but no harm at all.

Khalifa Sharquie MD, Professor, Iraqi Board for Medical Specializations, Chairman of Scientific Council of Dermatology, Baghdad, Iraq on October 29, 2009

This case is unique as it has spread through lymphatics as sporotrichosis like. I recommend to use oral zinc sulfate 150mg tds after meals and topical 15%zinc sulfate solution twice a day for at least one month. This is an effective treatment that has been used for many years and we have many publications in this field.

Ref: Sharquie KE, Najim RA, Farjou IB, Al-Timimi DJ. Oral zinc sulphate in the treatment of acute cutaneous leishmaniasis. Clin Exp Dermatol. 2001 Jan;26(1):21-6.

A clinical trial to evaluate the efficiency of oral zinc sulphate in the treatment of cutaneous leishmaniasis was conducted. One-hundred and four patients with parasitologically proven cutaneous leishmaniasis were included in the trial. Patients were assigned randomly to receive 2.5, 5 or 10 mg/kg of zinc sulphate orally, and a control group of patients did not receive any treatment. All patients were followed up for 45 days. At the end of the follow-up period, lesions were assessed and parasitological proof of cure or otherwise was sought. Results showed that the cure rate for the 2.5 mg/kg group was 83.9%, for the 5 mg/kg treatment group it was 93.1% and for the 10 mg/kg treatment group it was 96.9%. No lesions in the control group showed any sign of healing during the follow-up period. Therefore, oral zinc sulphate can be recommended as a very safe therapy for cutaneous leishmaniasis.

Fadi Hajjaj MBBS, DDSc, MSc, Postgraduate Doctor (MD Degree), Department of Dermatology, Cardiff University, Cardiff, UK on October 29, 2009

Thanks Dr Sobel for your presentation of this case. From my experience back in the Abu Dhabi,UAE, leishmaniasis is relatively common. We see it mainly in people who had traveled to areas such as Pakistan, Iran, Iraq and other middle eastern countries.

Pentostan is quite effective if given locally or through IM route, but it was not available in UAE and patients used to bring it from their home countries. I had experience with one case which I had treated with itraconazole 200 mg twice daily for 3-4 weeks with satisfactory response but not complete clearance. Anyway, you have the choice of leaving it without treatment since majority, if not all cases, will heal spontaneously but with some time!

Larry Erickson, M.D., Dermatologist, Group Private Practice, Sebastian, FL, USA on October 30, 2009

I would recommend treating one of the smaller lesions with cryosurgery. If it responds, then try treating the other lesions in a similar manner. Cryosurgery might trigger a host immune response.

Nasser Altamimi , Dermatologist, Yemen on October 30, 2009

Thanks, Dr Sobel for your presentation of this case.

Treatment has traditionally been unsatisfactory because of drug toxicities, poor responses, multiple disease syndromes, and other factors - including recently, the emergence of antimony-resistant strains. Orally administered miltefosine 100 mg/day (2.5 mg/kg/day) for four weeks has recently shown great promise (cure rate of 95% at six months post-treatment) in the treatment of Indian visceral leishmaniasis .

Other treatments include sodium stibogluconate (a pentavalent antimony compound) 20 mg/kg/day IM or IV once daily for 40 days if the disease was contracted in India and 28 days if contracted elsewhere. Sodium Stb is not FDA approved and must be obtained from the CDC. Side effects of sodium stibogluconate include changes in liver function, biochemical pancreatitis, EKG changes, musculoskeletal symptoms, thromboctopenia, and others. Second line treatments (used in some cases as a first line treatment) are amphotericin B total IV dose of 6-20 mg/kg over 20 doses (better results with higher dosing) or L-ampho 3.0 mg/kg IV day 1, day 5, day 10. Second line treatments include IM pentamidine 2-4 mg/kg/day for 15 days (or every other day) or IM aminosidine 15 mg/kg/day for 30 days. Second line medications (except for miltefosine) are sometimes given in combination with antimony compounds.

Bushan Kumar, MD, Consultant Dermatologist, Chennai, India, on October 31, 2009

I feel Sodium Stibogluconate in the dose of 20mg/Kg body weight given IV or IM for at least  three weeks is the best treatment which is safe and effective. People have tried oral rifampicin and parentral gold successfully. But there are no large scale studies to support to use of these two drugs.

Nurul Amin, MD, FCPS, FRCP , Professor, United Hospital ltd,Gulshan-2, Dhaka, Bangladesh on November 5, 2009

This is a unique case. Good photo. You can treat with pentamidine, itraconazole or amphotericin B.

Sam Moshella MD, Clinical Professor of Dermatology, Emeritus, Harvard Medical School, Boston, USA on November 11, 2009

Would you consider a therapeutic trial with miltefosine?

(Miltefosine is an oral agent that has been shown in small numbers of patients to have a favorable therapeutic index for Indian visceral leishmaniasis, mucocutaneous and CL in South America.. Oral miltefosine, an antitumour agent, is contraindicated during pregnancy; concomitant oral contraceptives should be prescribed for women of child-bearing age)

Sabah Hassan, MD, FICMS, Dermatologist, Iraq on November 24, 2009

The usual therapy to start with is antimonials, but if it does not respond I find rifampicin as a good alternative; I had treated two cases of Cutaneous Leishmaniasis with rifampicin 15 mg/kg/day after no response to antimony and they show very good response within three weeks of treatment.

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