P3.088: From Travel to Treatment: Pediatric Cutaneous Leishmaniasis

Introduction: Leishmaniasis is a vector-borne parasitic infection transmitted to humans by infected sandflies. Common forms include cutaneous (CL), mucocutaneous, and visceral (kala-azar). It occurs world-wide, particularly in tropical or subtropical climates. Most patients diagnosed in the U.S. were infected while exposed abroad. Leishmaniasis can affect quality of life given the debilitating, potentially disfiguring, and stigmatizing disease. Given global migration, awareness of this disease and its treatment in children is imperative.

Case Description: Two healthy teen siblings presented with cutaneous ulcers one month after arriving in the U.S. from Venezuela. Their journey, largely on foot, included crossing the Darién Gap, a 60-mile stretch of dense rainforest and wet terrain. The lesions began as small, raised bumps that progressed to 2-4 cm non-tender, annular ulcers with central honey-colored crusting and indurated raised borders. Multiple lesions were located on the lower leg for one sibling and upper back for the other. They were treated for superficial infections in local emergency visits with oral antibiotics without improvement.

The older teen was ultimately seen in dermatology clinic where a punch biopsy revealed Leishmania amastigotes on Giemsa stain, confirmed to be Leishmania (Viannia) guyanensis via PCR. No naso-palatal lesions were noted. Both siblings were started on miltefosine for 28 days with weekly lab monitoring for cell line dysfunction, hepatitis, and renal dysfunction. Challenges with wound care included their temporary housing in a church, which lacked shower or bathtub access. They were unable to go to school due to the large, painful, and visibly draining wounds. At two-week follow-up, their lesions had significantly improved. Due to transportation challenges, they missed their next appointment and were ultimately lost to follow-up.

Discussion: Awareness of leishmaniasis' diverse presentations and complications, especially mucocutaneous forms, is crucial. While some cutaneous cases self-resolve or respond to topical treatment, systemic therapy is necessary for complicated CL at risk of dissemination. Benefits of treatment include accelerated healing, lower recurrence, reduced severity of scarring, and decreased risk of metastatic infection, particularly with the Viannia subgenus. For children, systemic options include intravenous liposomal amphotericin and oral miltefosine. To avoid hospitalization, oral miltefosine was prescribed, though access to this medication can be cost-prohibitive. Ultimately, the medication was donated for both teens as it was not covered by insurance. Social work assisted with stable housing resources, local food banks, and wound care supplies.

Conclusion: This case demonstrates the importance of awareness of leishmaniasis for appropriate evaluation, treatment, and avoidance of complications. Challenges included addressing access to medication, housing, sanitation, and nutrition to promote healing. As providers, it is important to consider travel history as well as social and economic contributors to health.