Old World cutaneous leishmaniasis is a widespread and potentially disfiguring protozoal infection that is endemic in the Mediterranean basin, Africa, and parts of Asia. Human infection is caused by several species of Leishmania parasites, such as Leishmania infantum. Available systemic and topical treatments vary in efficacy and are often unjustified due to their toxicity. We report on a case that was treated with posaconazole, a drug typically considered an antifungal agent but which also targets specific metabolic pathways of the parasite.Leishmania infantum is a known cause of Old World cutaneous leishmaniasis (OWCL). In acute OWCL, the lesion is usually limited to one or a few papules, plaques, or nodules that evolve over a period of months to the ulcerous form (4, 12). Treatment options for OWCL include topical paromomycin ointment, local infiltration with antimonials, thermotherapy, or miltefosine (5). However, except for thermotherapy, these treatments are not U.S. Food and Drug Administration (FDA) approved. Use of these therapies is also limited by variable efficacy and local and systemic side effects that affect tolerability and compliance (4, 5). We describe a patient with OWCL who is successfully treated with posaconazole, an oral drug typically considered an antifungal agent but which also targets specific metabolic pathways of the parasite.We report a 36-year-old Caucasian woman with a small, papular, and very itchy right wrist lesion that had been present for 1 month. Originally from Australia, she had been living in New York City for 12 years. She had traveled to Malta and Dubai 6 months earlier but was well during both trips. At presentation, she had no systemic complaints and appeared healthy. There was a small 1-cm by 1-cm, erythematous, keloidlike papule at the ulnar surface of the right wrist but no epitrochlear or axillary lymphadenopathy. The results of a complete blood count and chemistry and hepatic transaminase tests were within normal limits before and throughout the treatment period. Histologic examination of a shaved biopsy specimen of the lesion demonstrated Leishmania parasites (Fig. 1A and B, inset).Biopsy specimens were also preserved in 70% ethanol for molecular testing. DNA was extracted using the phenol-chloroform method, suspended in Tris-EDTA (TE) buffer, and stored at 4°C until use. The Leishmania parasites were identified as L. infantum by the ribosomal DNA internal transcribed spacer 1 (ITS1) PCR using the primers LITSR and L5.8 (Fig. 2). The ITS1 PCR product (ϳ320 bp) was sequenced in the Department of Genetics of the Humboldt University of Berlin by employing the same primers used for PCR. The sequences obtained were processed and aligned against those of different Leishmania species deposited in GenBank, using the multiple alignment program BioEdit, and edited manually. The ITS1 sequence submitted to GenBank under accession number FR675940 demonstrated that the OWCL in our patient was due to L. infantum infection. Microsatellite analysis failed to reveal strain-specif...

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Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) have been considered prevalent pathogens in foot infections. However, whether empiric therapy directed against these organisms is necessary, and in whom to consider treatment, is rather unclear. The aim of this study was to develop predictive algorithms for forecasting the probability of isolating these organisms in the infected wounds of patients in a population where the prevalence of resistant pathogens is low. This was a retrospective study of regression model-based risk factor analysis that included 140 patients who presented with infected, culture positive foot ulcers to two urban hospitals. A total of 307 bacteria were identified, most frequently MRSA (11.1%). P. aeruginosa prevalence was 6.5%. In the multivariable analysis, amputation (odds ratio (OR) 5.75, 95% confidence interval (CI) 1.48–27.63), renal disease (OR 5.46, 95% CI 1.43–25.16) and gangrene (OR 2.78, 95% CI 0.82–9.59) were identified as risk factors associated with higher while diabetes (OR 0.07, 95% CI 0.01–0.34) and Infectious Diseases Society of America infection severity >3 (OR 0.18, 95% CI 0.03–0.65) were associated with lower odds of P. aeruginosa isolation (C statistic 0.81). Similar analysis for MRSA showed that amputation was associated with significantly lower (OR 0.29, 95% CI 0.09–0.79) risk, while history of MRSA infection (OR 5.63, 95% CI 1.56–20.63) and osteomyelitis (OR 2.523, 95% CI 1.00–6.79) was associated with higher odds of isolation (C statistic 0.69). We developed two predictive nomograms with reasonable to strong ability to discriminate between patients who were likely of being infected with P. aeruginosa or MRSA and those who were not. These analyses confirm the association of some, but also question the significance of other frequently described risk factors in predicting the isolation of these organisms.