Leishmaniasis in Emergency Medicine Treatment & Management

  • Author: Jennifer J Lee, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Aug 16, 2010
 

Emergency Department Care

  • Cutaneous leishmaniasis
    • Treatment of cutaneous leishmaniasis differs according to the etiology and geographic location of the infection. For certain types of cutaneous leishmaniasis where the potential for mucosal spread is low, topical paromycin can be used.
    • For more invasive lesions (eg, those failing to respond to topical treatment; metastatic spread to the lymph nodes; or large, disfiguring, and multiple skin lesions, especially those on the face, near mucosal surfaces, or near joints), sodium stibogluconate or pentamidine can be used.
    • Other reported treatments include meglumine antimonite in addition to topical imiquimod cream, cryotherapy, heat therapy (radiofrequency), ketoconazole, itraconazole, allopurinol, or miltefosine (not available in the US).
  • Mucosal leishmaniasis
    • Pentavalent antimony for a course of 4 weeks has been recommended.
    • Amphotericin B deoxycholate may be first-line therapy for advanced mucosal disease.
  • Visceral leishmaniasis
    • Be alert for complications related to reticuloendothelial system failure. Patients may have bleeding or neutropenia leading to infectious conditions such as pneumonia or diarrhea. Transfusions may be necessary for severe bleeding or anemia. Antibiotics are indicated to treat intercurrent infectious conditions.
    • Outside of India, treatment with a pentavalent antimonial compound usually is effective. The use of an alternative parenteral agent should be considered even for first-line therapy in areas where resistance to pentavalent antimony therapy is prevalent, as it is in India, or if nonantimonial therapy would be advantageous for other reasons (eg, toxicity profile, duration of therapy).
    • A major advance has been the advent of liposomal formulations of amphotericin B, in which various alternative lipids have replaced deoxycholate. These formulations, which passively target amphotericin to macrophage-rich organs, are much more costly than conventional amphotericin B (making them cost-prohibitive in poor countries) but are associated with less nephrotoxicity and can be given in considerably shorter courses. Although visceral leishmaniasis is traditionally treated with multiple doses of amphotericin B deoxycholate, it appears, based on a single randomized trial, that a single dose of liposomal amphotericin B may be just as effective and cheaper.[2]
    • Other parenteral alternatives that have merit include amphotericin B (not only in deoxycholate form but also in liposomal forms) and have generally replaced pentamidine. Miltefosine, a chemotherapeutic agent, is the first extremely effective oral agent for visceral leishmaniasis but is not currently available in the United States. Injectable paromycin has also been reported to be noninferior to amphotericin B but also is not currently FDA approved.
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Consultations

  • Infectious disease consultation can offer the most effective antiprotozoal regimen.
  • Although cutaneous leishmaniasis can heal on its own, early lesions can also be treated with physical measures, such as local cryotherapy, heat therapy, electrocoagulation, or surgical removal.
  • Surgical consultation may be necessary for adjunctive splenectomy.
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Contributor Information and Disclosures
Author

Jennifer J Lee, MD  Attending Physician, Department of Dermatology, Beth Israel Deaconess Medical Center, Boston; Instructor, Department of Dermatology, Harvard Medical School

Jennifer J Lee, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Renee Y Hsia, MD, MSc  Clinical Instructor, Division of Emergency Medicine, University of California at San Francisco; Attending Physician, Department of Emergency Medicine, San Francisco General Hospital

Renee Y Hsia, MD, MSc is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, American College of Surgeons, American Heart Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John Halpern, DO, FACEP  Clinical Assistant Professor, Department of Family Medicine, Nova Southeastern University College of Osteopathic Medicine; Medical Director, Health Career Institute; Medical Director Emergency Department, Palms West Hospital

John Halpern, DO, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Edmond A Hooker II, MD, DrPH, FAAEM  Assistant Professor, Department of Emergency Medicine, University of Cincinnati College of Medicine

Edmond A Hooker II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, and Southern Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Jeter (Jay) Pritchard Taylor III, MD  Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina School of Medicine; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist

Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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Leishmaniasis. Image courtesy of the CDC Public Health Image Library.
Leishmaniasis. Photo courtesy of Robert Norris, MD, Stanford University Medical Center.
Leishmaniasis. Photo courtesy of Robert Norris, MD, Stanford University Medical Center.
Leishmaniasis. Image courtesy of the CDC Public Health Image Library.
Leishmaniasis. Ethiopian woman with 1-year history of asymptomatic pink-erythematous infiltrative plaque with overlying scale and central crust.
 
 
 
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