Snapshot A 38-year-old recent immigrant from Brazil comes into the clinic with a four month history of painless ulcerated plaques on his left arm. He denies fever, fatigue, or weight loss. Past medical history revealed the patient is being treated for ankylosing spondylitis with methotrexate and adalimumab. Physical exam revealed ulcers of varying sizes on the left arm, covered with a yellow-white fibrinous material. There are no mucosal lesions, pallor, lymphadenopathy, or hepatosplenomegaly. A complete blood count and liver function test was within normal limits. HIV serology, AAFB for lepra bacilli, and serum VDRL were all negative. Histopathological exam of a skin biopsy showed amastigotes inside histiocytes and inflammatory cells. PCR assay results are pending. Introduction Classification protozoan parasite Leishmania Epidemiology location tropical and subtropical countries mostly a disease of the developing world Transmission phlebotomine sand flies Presentation Manifests in various forms cutaneous leishmaniasis (most common) causing skin sores can cause disfiguring facial lesions visceral leishmaniasis affects internal organs such as the spleen, liver, and bone marrow can be highly fatal Symptoms cutaneous papules or nodules ulcerations usually painless but can be painful visceral fever weight loss hepatosplenomegaly anemia leukopenia thrombocytopenia Leishmania donovani particular species of Leishmania particular to the visceral infection Evaluation Blood smear stained with Giemsa or Leishman's stains direct visualization of the amastigotes makes the diagnosis PCR assay Tissue specimens from skin sores Differential Cutaneous disease leprosy sporotrichosis squamous cell carcinoma cutaneous tuberculosis Visceral disease malaria histoplasmosis lymphoma Treatment Conservative protection from sand fly bites stay indoors from dusk to dawn (when sand flies are most active) wear long pants and shirt for extra skin coverage insect repellent skin sores will usually heal on their own Pharmacologic amphotericin treatment of choice less resistance than the antimony-containing therapies approved for treatment of visceral leishmaniasis meglumin antimoniate high resistance sodium stibogluconate high resistance adverse effects exceedingly phlebotoxic pancreatitis miltefosine for visceral and cutaneous fluconazole effective in treating cutaneous leishmaniasis Prognosis, Prevention and Complications Prognosis cutaneous lesions may resolve without treament visceral disease has a poorer prognosis if there is HIV co-infection Prevention protection from sandfly bites no vaccines currently Complications cutaneous disease can persist for years post kala-azar dermal leishmaniasis