Overview of Cutaneous Leishmaniasis Skin Disease

Cutaneous Leishmaniasis is a skin disease that leave marks on the skin. It has been identified in some refugees who have left Syria. This is no surprise. It's a disease that's found around the world and specifically has been found for a long time in Syria.

It does cause skin lesions, but, Cutaneous Leishmaniasis isn't as bad as it might sound.

Leishmaniasis is often thought of as a dangerous disease. Sometimes, it is. But not usually the Cutaneous form. Cutaneous Leishmaniasis is not Visceral Leishmaniasis. Cutaneous Leishmaniasis does not kill. Visceral does. Because both are called Leishmaniasis, they are often confused.

The two different types of Leishmaniasis are caused by different species (from among the 21 that infect humans). And so, there is often an unwarranted fear about Cutaneous Leishmaniasis (CL or sometimes Cutaneous Leish for short). Most cases of Leish in Syria are Cutaneous. (Beyond VL and CL, there's also mucocutaneous, which is mostly found in Brazil, Peru, and Bolivia. There can be recurrent cases especially in the Middle East.)

What does Cutaneous Leishmaniasis do? 

Cutaneous Leish is described as a skin infection that is  "self-healing and typically leaves a depressed scar". That is to say, Cutaneous Leish causes an unsightly lump/depression of skin that usually goes away without treatment. It is not usually painful.  It might become painful, if it were to be  super-infected by bacteria or was over a joint. It doesn't do much more than that.

How does it spread?

Sandfly bite. Specific species of Sandflies are needed to spread the parasites that cause Leish. Sometimes the parasite goes from animal to sandfly to person. Other times, it jumps person to sandfly to person.

Two Leish parasites that spread CL can spread in different ways with different sandflies. Very specifically, the parasite Leshmania major is transmitted by sandfly Phlebotomus papatasi from an animal to people. The parasite Leishmania. tropica is transmitted by sandfly P. sergenti from person to person.

This means if someone moved from Syria to the US, they wouldn't spread the infection because the sandflies wouldn't be present.

However, in rare cases, it could be spread by blood transfusion.

So what's the problem?

(a) No one likes a scar 

(b) No one likes the ideas of a scarring infection that is contagious. (Fortunately, it is only contagious through a sandfly bite)

(c) High rates of Leish may point to issues with sanitation and waste removal, lack of continued spraying for sand flies (or mosquitoes), and overcrowding that allows sandflies to reproduce and spread Leish between people or between people and mammals (like rats).

What was the situation like in Syria?

Cutaneous Leish, caused by L tropica, was especially endemic in Aleppo - and some L major. Syria saw 30,000 cases a year before the war and it has been rising throughout the war (and well before, actually). So it's not surprising that some people had Leish.

Iraq already had Leish - L major (and more Visceral as well). Lebanon has, in particular, been having the deal with this sudden  importation of Leish after being free of it for a decade. they unfortunately had a compatible sandfly. (Greece also has a history of having the same strain of Leish as Aleppo has had - well before any of this).

How is it treated?

Cutaneous Leish is often treated with multiple direct injections.

Care of CL patients - even in the US - can mean simply doing what's best and just watching the lesion heal on its own without treatment. The specific treatments for Leish are not the easiest. Risks may outweigh benefits, especially for treatment that's systemic and not injected into the lesion. Many lesions may simply be covered with gauze which can help avoid bacterial contamination. However, many lesions are treated with injections of very specific medications directly into the lesions. (Specifically, meglumine antimoniate intralesional treatment). These injections may need to be done weekly until the case resolves. This is especially done for lesions on the face, such as on the eyelids especially.

Is there resistance or prolonged cases?

There has also been concern for increasing resistance. L tropica, the species from Aleppo, is also known for being more likely to be chronic than other species and there are reports of more cases resistant to treatment.

Is there Visceral Leishmaniasis? 

It should also be noted that there are occasional cases reported of Visceral Leishmaniasis. This was rare. 17 cases in Syria in 2008. Iraq has had a lot more. Among refugees in Syria, 2 out of close to 1000 were Visceral. It is harder to diagnose, but if this were found, this would be a different problem.

What are the steps to avoiding Sandflies?

To stop Leish spreading, Sandflies have to stop biting infected people and those around them.

- Sandfly Vector Control (possibly spraying)

- Waste removal - stops Sandfly breeding ground and rats (which spread L major)

- Bed Nets (not all agree on this; WHO in favor)

- Avoid Over-Crowding (as sandflies can jump from blood meal to blood meal)

- Medical attention could reduce cases as the Leish found in Syria spread largely human to sandfly to human (anthroponotic). Longer cases remain in community being bitten, the longer Leish will spread.

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