Mucocutaneous leishmaniasis (espundia): what it is and how it is treated

Leishmaniasis is a parasitic disease transmitted by the bite of infected phlebotomine sandflies, according to DermNet NZ. There are several clinical forms, and which one develops depends on the species of Leishmania and the person's immune response. DermNet describes mucocutaneous leishmaniasis as a destructive form that is only seen with the American species, the Viannia subspecies, with Central and South America as the location.

There is no NHS patient information page for mucocutaneous leishmaniasis, as it is an imported infection seen only in specialist centres. This page therefore draws on DermNet NZ, a New Zealand dermatology reference updated by a UK dermatologist, and on a UK case series from a specialist centre, and is not a substitute for specialist advice.

The infection usually starts as a cutaneous lesion at the bite site. DermNet says that this typically begins as a small red papule that gradually enlarges, often with central ulceration, usually painless, appearing on exposed areas, with an incubation time of 2 weeks to 6 months. Many resolve spontaneously, often leaving scarring.

Mucocutaneous disease typically occurs after spontaneous resolution or local treatment of the primary lesion, and may develop within months or after many years. DermNet says the lesions usually affect the mucous membranes of the nose and mouth, though the eyes and genital tract can be involved, and that without treatment ulceration of the mucosal surfaces and destruction of underlying tissue can occur, with painful lesions that become secondarily infected, sometimes leading to sepsis, and extreme disfigurement.

Because the mucosal stage may be years after the skin sore, the early signs can be easily overlooked, and a history of a non-healing skin sore after travel in Latin America is a key clue. DermNet describes the mucosal lesions as usually affecting the nose and mouth, and as often painful.

• Painful ulcers or sores in the lining of the nose or mouth.

• Persistent nose or mouth symptoms that do not settle with usual treatment.

• Visible tissue damage or disfigurement of the nose or mouth in advanced disease.

• A history of a skin sore after time in Central or South America.

If you have returned from Central or South America with a skin sore that has not healed, see a GP and mention the travel. If you had such a sore in the past and now have persistent nasal or mouth symptoms, seek assessment and say so, even if the trip was years ago. Referral is to an infectious diseases, tropical medicine or dermatology service. Seek urgent help for fever, severe pain, spreading redness or breathing difficulty.

DermNet explains that diagnosis is based on history and clinical appearance, with a comprehensive travel history, including historical travel because of the long incubation period, important in non-endemic areas. The diagnosis can be confirmed by identifying the parasite on biopsy or split-skin smear, and culture and PCR may be used to confirm the diagnosis and identify the species, which is important when there is a risk of mucocutaneous disease. Histopathology is used to establish mucocutaneous leishmaniasis.

DermNet says systemic antimonials, sodium stibogluconate or meglumine antimoniate, are the mainstay of treatment for complex cutaneous lesions, mucocutaneous disease and visceral leishmaniasis. They cannot be given orally, the length of treatment may be up to 28 days for mucosal lesions, treatment requires hospital admission, and there is a risk of side effects including cardiotoxicity. Non-antimonial options include amphotericin B, miltefosine and pentamidine.

A report from a UK specialist centre describes 67 patients with New World cutaneous leishmaniasis treated as day cases with sodium stibogluconate for up to 28 days, with blood tests and ECGs twice weekly. It found temporary falls in lymphocytes and platelets and rises in liver enzymes that did not cause adverse clinical events, and concluded that in specialist centres selected patients under 65 without other illnesses can be treated without hospital admission. This shows that treatment is highly specialised and carefully monitored.

DermNet says infection can be prevented by avoiding sandfly bites, since there are no vaccines or drugs for preventing infection. It advises avoiding outdoor activities at dusk and dawn, wearing long sleeves and trousers, using insect repellent containing DEET on exposed skin, and treating clothing and bed nets with permethrin. A travel clinic can advise before a trip to endemic areas.

Leishmaniasis is managed by NHS infectious diseases and tropical medicine specialists, who can arrange species testing and treatment. Private travel clinics offer pre-travel advice but treatment of mucosal disease needs a specialist centre with the experience and the monitoring facilities.