With approximately 1.3 million infections and more than 50,000 deaths every year, leishmaniasis is an important infectious disease that has an endemic status in the majority of Latin America, countries of the Mediterranean basin, the Middle East, and certain areas of Africa and Asia [1] [2] [3] [4] [5] [6]. The protozoan parasite Leishmania, the causative agent of leishmaniasis, is transmitted to the human host by the sand fly vector from a number of animal hosts (or other human hosts that are already infected, in which case the term anthroponotic leishmaniasis is used) [1] [3]. Mucocutaneous leishmaniasis is one of the three clinical forms (in addition to visceral and cutaneous) of this parasitic infection, distinguished by the onset of lesions on the skin and on mucous membranes as well [1] [2] [3] [4] [7] [8]. Certain Leishmania species (L. braziliensis, L. major, L. panamensis, L. guyanensis, L. infantum, and L. donovani) are known for their propensity to produce mucocutaneous forms that start with the development of an erythematous papule at the site of the sand fly bite [1] [3]. The face and the extremities are usually the locations of the initial lesion, which can appear weeks or even years after the bite [1] [3]. Over time, the papule increases in size and eventually breaks, leading to the formation of a painless, well-demarcated ulcer [1] [3]. Spontaneous resolution within a few months is seen in the majority of cases, but new lesions might appear at various sites on the body [1] [3]. The distinguishing feature of mucocutaneous leishmaniasis is the mucosal involvement, predominantly in the oral cavity and the nasopharynx [2] [8].

• Fever

  The main side effects were headache and fever (7 cases), together with leucopenia and eosinophilia (4 cases). [ncbi.nlm.nih.gov]

  There may be fever, chills, malaise, cough, anorexia, anemia, and wasting. The Leishmania organisms multiply in the cells of the reticuloendothelial system, eventually causing hyperplasia of the cells, especially those of the liver and spleen. [medical-dictionary.thefreedictionary.com]

  [Dunglison1855] The Low Fever Typhus Mitior in Latin. [Hooper1822] Low Continued Fever Typhoid Fever, Febricula, Little Fever. [Symptom, Nature, etc. of the Febricula or Little Fever, Manningham, 1746]. [antiquusmorbus.com]

  Rickettsia Rickettsii and Other Spotted Fever Group Rickettsiae (Rocky Mountain Spotted Fever and Other Spotted Fevers) 188. Rickettsia Akari (Rickettsialpox) 189. Coxiella Burnetii (Q Fever) 190. [euro-libris.ro]

  Symptoms include fever (often 2 fever spikes per day), enlargement of the spleen and liver, weakness, and progressive emaciation. The disease is often fatal without treatment, but survivors often develop immunity. [msu.edu]

• Generalized Lymphadenopathy

  • Infection and multiplication in cells of the monocyte/macrophage line leads to generalized lymphadenopathy and splenomegaly. • Immune complex formation contributes to the pathological changes. • Visceral leishmaniasis is a chronic wasting disease [leishmaniasis.info]

  Other manifestations may include generalized lymphadenopathy; hyperpigmented skin of the forehead, abdomen, hands, and feet in light-skinned persons; skin lesions in dark-skinned persons; signs of bleeding (petechiae, epistaxis, bleeding gums); jaundice [wynman.com]

• Nasal Ulcer

  A 55-year-old man presented with a nasal ulcer of four years' duration. He had been treated for borderline lepromatous (BL) leprosy 25 years earlier. Differential diagnoses of MCL, lupus vulgaris, and subcutaneous mycosis were considered. [ncbi.nlm.nih.gov]

• Nasal Congestion

  A 35-year-old man with nasal congestion, swelling, and pain. N Engl J Med 2005;352:609-15. 3. Vera LA, Macedo JL, Ciuffo IA, Santos CG, Santos JB. [ijdvl.com]

• Respiratory Insufficiency

  Left untreated, mucocutaneous leishmaniasis leads to malnutrition and acute respiratory insufficiency, which are the two primary causes of death in fatal cases. [the-medical-dictionary.com]

• Palpitations

  Treatment with liposomal amphotericin B was started but was soon terminated because of palpitation, epigastralgia and facial flushing. [ncbi.nlm.nih.gov]

• Lacrimation

  PURPOSE: This study describes lacrimal tract involvement and surgical outcome in patients with mucocutaneous leishmaniasis. [ncbi.nlm.nih.gov]

• Skin Lesion

  The helper/suppressor (H/S) ratio in the skin lesions was 1.6 /- 0.5 and in the nasal lesions of mucosal leishmaniasis was 1.7 /- 0.8. [ncbi.nlm.nih.gov]

  The treatment measures include: Oral medicines and topical ointments/applications for skin lesions: The ulcers do not go away on their own without suitable treatment If the ulcers heal and cause cosmetic disfigurement, then plastic surgery may be performed [dovemed.com]

  One year later, physical examination revealed that the patient experienced a marked improvement and the skin lesions had almost disappeared. [the-medical-dictionary.com]

• Skin Disease

  Mucocutaneous disease is due to extension of local skin disease into the mucosal tissue via direct extension, bloodstream or lymphatics. Lesions interest mainly the oral and nasal mucosa and occasionally the laryngeal and pharyngeal mucosa. [ncbi.nlm.nih.gov]

  "Dallas News: Rare, non-fatal skin disease found in N. Texans". Archived from the original on 27 December 2009. Retrieved 2 June 2015. "Papalomoyo" (PDF). Archived from the original (PDF) on 23 July 2011. Retrieved 16 August 2010. [en.wikipedia.org]

  Old World cutaneous leishmaniasis is a mostly self-limiting skin disease in adults, but depending on the species, infected infants and children can develop the visceral form of the disease. [iamat.org]

  On DermNet NZ Bugs Arthopod bites and stings Tropical skin diseases Other websites Leishmaniasis – pathology Leishmaniasis – Medline Plus Leishmaniasis – World Health Organization (WHO) Leishmaniasis – Medscape Reference Books about skin diseases See [dermnetnz.org]

  Leishmania infection can cause skin disease (called cutaneous leishmaniasis). [the-travel-doctor.com]

• Skin Ulcer

  Four patients presented with large skin ulcers, and 9 had mucosal involvement as the main manifestation, the latter affecting the nose (3 cases), nose and septum (2 cases), nose and oral cavity (1 case), and nose, pharynx and larynx (3 cases). [ncbi.nlm.nih.gov]

  Cutaneous leishmaniasis (CL) can produce large numbers of skin ulcers—as many as 200 in some cases—on the exposed parts of the body, such as the face, arms and legs, causing serious disability and leaving the patient permanently scarred. [the-travel-doctor.com]

  Mucocutaneous leishmaniasis A rare form of the disease, mucocutaneous leishmaniasis is caused by the cutaneous form of the parasite and can occur several months after skin ulcers heal. [healthline.com]

  Cutaneous leishmaniasis causes skin ulcers; mucocutaneous leishmaniasis causes destructive lesions of the mucous membranes of the nose, mouth, and throat; visceral leishmaniasis is the most severe form of the disease and is manifested with anemia, weight [fpnotebook.com]

• Cutaneous Manifestation

  Yet the infrequency of mucocutaneous disease compared with cutaneous manifestations, and the difficulty of isolating parasites from mucocutaneous lesions have restricted the study of the organisms involved. [ajtmh.org]

  Therefore, these lesions can be confused with those found in Wegener's granulomatosis (which is also marked by cutaneous manifestations and can involve the nasal mucosa), leprosy, and tuberculosis. (9) Cultures and recombinant immunoenzymatic testing [the-medical-dictionary.com]

  A range of cutaneous manifestations occurs due to Leishmania infection. The species of parasite is the most important determinant of clinical outcome. [mdpi.com]

  manifestations can be further subdivided into localized, diffuse (disseminated), recidivans, and post–kala-azar dermal leishmaniasis Geographic occurrence: Old World leishmaniasis is caused by Leishmania species found in Africa, Asia, the Middle East [emedicine.medscape.com]

• Tropical Ulcer

  Differential Diagnosis: Numerous primary and secondary skin diseases/conditions such as other tropical ulcers, impetigo, infected insect bites, leprosy, lupus vulgaris, tertiary syphilis, yaws, blastomycosis, skin cancer, and others. [wynman.com]

A thorough clinical approach is necessary in order to make the diagnosis of mucocutaneous leishmaniasis. A meticulously obtained patient history should be the first step, during which the physician must bear in mind the country of residence and travel to endemic areas in the past several years, whereas a history of sand fly bites might be assessed as well. A properly conducted physical examination, with an emphasis on the inspection of the skin and the oral cavity, may be even more important for identifying the lesions seen in mucocutaneous leishmaniasis. To solidify clinical suspicion, however, several microbiological tests can be employed. Scrapings from the lesions are used for microscopic smear examination or cultivation, the former being a superior method due to the longer turnaround time of cultures (up to 10 days are necessary for Leishmania to grow on standard media) [3] [4]. A histological examination of a biopsy sample (using hematoxylin-eosin staining) can be carried out, but the introduction of serological and molecular studies have greatly improved the overall rate of diagnosis [3] [4]. The Montenegro's test, comprised of inoculating Leishmania antigen into the forearm, can yield conclusive results after 72 hours [3] [4] [8]. Polymerase chain reaction (PCR), although being expensive and more sophisticated compared to the previously mentioned methods, should be implemented whenever possible, primarily because of its very high sensitivity/specificity rates [3] [4] [9].

• Leishmania in Tissue

  Detection and characterization of leishmania in tissues of patients with post kala-azar dermal leishmaniasis using a specific monoclonal antibody. Trans. R. Soc. Trop. Med. [mdpi.com]

1. Palumbo E. Treatment strategies for mucocutaneous leishmaniasis. J Glob Infect Dis. 2010;2(2):147-150.
2. Elmahallawy EK, Sampedro Martinez A, Rodriguez-Granger J, et al. Diagnosis of leishmaniasis. J Infect Dev Ctries. 2014;8(8):961-972.
3. Masmoudi A, Hariz W, Marrekchi S, Amouri M, Turki H. Old World cutaneous leishmaniasis: diagnosis and treatment. J Dermatol Case Rep. 2013;7(2):31-41.
4. Davies CR, Kaye P, Croft SL, Sundar S. Leishmaniasis: new approaches to disease control. BMJ. 2003;326(7385):377-382.
5. World Health Organization. The world health report. Geneva: WHO; 2002. Annex 3: Burden of disease in DALYs by cause, sex and mortality stratum in WHO regions, estimates for 2001; pp. 192–197.www.who.int/whr/2002/whr2002_annex3.pdf
6. Alvar J, Vélez ID, Bern C, et al. Leishmaniasis worldwide and global estimates of its incidence. PLoS One. 2012;7:e35671.
7. Savoia D. Recent updates and perspectives on leishmaniasis. J Infect Dev Ctries. 2015;9(6):588-596.
8. Diniz JL, Costa MO, Gonçalves DU. Mucocutaneous Leishmaniasis: clinical markers in presumptive diagnosis. Braz J Otorhinolaryngol. 2011;77(3):380-384.
9. Lemrani M, Hamdi S, Laamrani A, Hassar M. PCR detection of Leishmania in skin biopsies. J Infect Dev Ctries. 2009;3(2):115-122.