Pediatric emergency medicine trisk 582

Leishmaniasis is a parasitic disease caused by the protozoan flagellates of
Leishmania genus that are transmitted to humans through the bite of the
phlebotomine sandfly. The annual incidence is 1.5 to 2 million. The disease is
found worldwide in tropical zones, with most cases in South Asia and the Horn
of Africa. There are three major clinical manifestations including cutaneous,
mucosal, and visceral forms. Immunosuppression is a risk factor for the visceral
form. More than 90% of visceral leishmaniasis cases occur in the Middle East,
where as 90% of mucosal leishmaniasis cases occur in Peru, Brazil, and Bolivia.
Cutaneous leishmaniasis is more widely distributed and occurs in Central
America, northern South America, northern Africa, the Middle East, and
scattered portions of southern Europe. Cutaneous infection presents as painless
skin lesions localized to exposed parts of the body that are accessible to sandflies
(e.g., extremities, face). The incubation period is approximately 1 month. The
skin lesions initially present as erythematous papules, which evolve into nodules
and then to shallow volcano-like ulcerative lesions that are locally destructive
and have associated localized lymphadenopathy. Mucosal infection may occur
simultaneously or months to years after a cutaneous lesion heals. Parasites may
extend into the nasopharyngeal mucosa and cause nasal congestion. The
infection may continue to spread to the buccal mucosa and laryngeal membrane.
Advanced stages of the disease can involve severe tissue necrosis and
disfigurement. The incubation period for visceral leishmaniasis is 2 to 6 months
and the onset of symptoms may be acute or chronic. In sudden-onset cases,
patients develop a persistent high fever, anorexia, a protuberant abdomen, and
wasting of the limbs. Painless splenomegaly is an early finding; while
hepatomegaly is less common, icterus is a marker of poor prognosis.


TABLE 94.21
DERMATOLOGIC CONDITIONS SEEN IN RETURNING TRAVELERS

Morphology Disease

Region

Manifestations

Burrows

Central/South
America

Botfly embryo
penetrates hair
follicle and
develops into a
boil-like pocket

Botfly (myiasis)

Burrowing flea
(tungiasis)

Eschar

Ulcers

Caribbean, Latin
After impregnation,
America, Africa,
female flea

Indian subcontinent
burrows under
skin, releasing
eggs from boillike orifice
S. aureus, group A Global
Shallow, painful,
streptococcus
purulent lesions
that are
secondarily
infected by
pyogenic bacteria
Rickettsial
Africa, Asia
Subcentimeter
diseases
painless lesion at
the site of the tick
bite
Buruli ulcer
Americas, Africa,
Painless progressive
disease
Asia, eastern
ulcers with cotton
(Mycobacterium
Mediterranean
appearance and
ulcerans )
surrounding skin

hyperpigmentation
Leishmaniasis
Latin America
Papules which
(espundia )
become nodules
then shallow
Central Asia
painless ulcers
with raised
borders.
Granulomatous
inflammation can
be destructive;


most common on
the face

Urticarial

Sporotrichosis
(Sporothrix
schenckii)

Tropical/subtropical
regions in western
hemisphere

Cutaneous larva

migrans

Caribbean, Africa,
Migrating intensely
Asia, Latin
pruritic
America,
serpiginous tracks
southeastern United
most common on
States
buttocks and feet

Onchocerca
Sub-Saharan Africa
volvulus (river
blindness)
Sea anemone
Caribbean, Latin
larvae
America,
(Edwardsiella
Philippines,
lineata ),
Southeast Asia
jellyfish larvae
(Linuche
unguiculata )
Scabies (Sarcoptes Worldwide
scabiei )

Ulcerative, papular,
or nodular lesions
at site of minor
trauma, usually
from contact with
soil. Can spread in
a lymphatic
pattern

Pruritic rash after
contact with
blackfly larvae
Pruritic papular rash
caused by larvae
entrapped under
the bathing suit

Pruritic
erythematous
eruption most
common in
webspaces of
digits and along
areas where
clothing fits
tightly; in infants,
diffuse rash can be
seen