Successful Treatment of Old World Cutaneous Leishmaniasis Caused by Leishmania infantum with Posaconazole

Abstract

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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