LOCALIZED CUTANEOUS LEISHMANIASIS
Lesions usually appear on the extremities or face (the ear in cases of chiclero ulcer) weeks to months after the bite of the sandfly. They first appear as pruritic papules, often accompanied by regional lymphadenopathy. In a few months the papules ulcerate, producing painless craters with raised erythematous edges, sharp walls, and a granulating base. Satellite lesions may form around the edge of the primary sore and fuse with it. Multiple primary lesions are seen in some patients. Spontaneous healing occurs in 3 to 12 months, leaving a flat, depigmented scar. Occasionally the lesions fail to heal, particularly on the ears, leading to progressive destruction of the pinna. A permanent strainspecific immunity usually follows healing. Multiple, disseminated nonhealing lesions may be seen in patients with acquired immunodeficiency syndrome (AIDS).
In endemic areas, the diagnosis is made on clinical grounds and confirmed by the demon-stration of the organism in the advancing edge of the ulcer. Material collected by biopsy, curettage, or aspiration is smeared and/or sectioned, stained, and examined microscopi-cally for the pathognomonic Leishman ‚Äď Donovan bodies. Material should also be cul-tured in liquid media. The leishmanin skin test becomes positive early in the course of the disease and remains so for life. Recently, it has been demonstrated that small numbers of Leishmania may be detected in tissue by the polymerase chain reaction (PCR), andstrains distinguished with probes to kinetoplast DNA. These techniques, although not widely available, permit direct, rapid, and specific diagnosis of all leishmanial infections.
Patients with small, cosmetically minor lesions that do not involve the mucous mem-brane may be carefully followed without treatment. Pentavalent antimonial agents and li-posomal amphotericin B have proved to be effective chemotherapeutic agents for individ-uals with more consequential lesions. Recently, ketoconazole and itraconazole, alone or in combination with the previously mentioned agents, have been found to be effective in some forms of cutaneous leishmaniasis. Bacterial superinfections are treated with appro-priate antibiotics. Prophylactic measures include the control of the sandfly vector by use of insect repellents and fine mesh screening on dwellings.