5-43
Subjective: Symptoms
Cutaneous: Non-healing skin lesion which is usually ulcerative. This skin sore often starts as a papule
that enlarges and ulcerates. Sometimes trauma to the skin can initiate the infection at a site distant to the
sandfly bite.
Visceral (kala azar): Fever often >104°F which can be intermittent, with chills, wasting, night sweats,
nonproductive cough, abdominal complaints, fatigue and an enlarged abdomen.
Focused History: Do you remember insect/sandfly bites? (exposure) Did you have trauma here before
this sore developed? (typical history) How long have you noticed your skin sore(s)? (tend to be chronic
and non-healing)
Objective: Signs
Using Basic Tools:
Cutaneous: Chronic skin lesions, usually ulcerative (see Color Plates Picture 19), but can be infiltrative or
papular; crust often forms over the surface and secondary bacterial infections can occur; usually on exposed
portions of the body (frequently extremities and face); regional adenopathy.
Visceral: Fever, wasting, lymphadenopathy, skin changes, hepatosplenomegaly; late peripheral edema, renal
failure and bleeding.
Assessment:
Differential Diagnosis
Cutaneous (chronic skin lesion) - sporotrichosis, syphilis, leprosy, neoplasm.
Visceral (fever and hepatosplenomegaly) - malaria, typhoid, typhus, acute Chagas’’ disease and
tuberculosis.
Plan:
Treatment: Primary:
Cutaneous: Usually self-limited. Old World cutaneous form may require ketoconazole and topical
medications, or pentavalent antimony for very difficult cases.
Visceral: Pentavalent antimony (sodium stibogluconate [Pentostam]) from Walter Reed Army Medical
Center.
Alternative: Liposomal amphotericin B can be used.
Patient Education
General: Avoid sandfly bites.
Activity: As tolerated
Diet: As tolerated
Medications: As tolerated
Prevention and Hygiene: Avoid sandfly bites.
Wound Care: Keep wound clean, dry and protected.
No Improvement/Deterioration: Return for referral to a higher level of care.
Follow-up Actions
Evacuation/Consultation Criteria: Cutaneous form requires non-urgent referral to a specialist in tropical
medicine. Visceral leishmaniasis is potentially life threatening so patient should be transferred to infectious
diseases/tropical medicine care urgently.
NOTES: Definitive diagnosis is made by identification of the cultured organism from biopsy of skin (cutaneous
disease) or liver/spleen or bone marrow (visceral disease). Walter Reed Army Medical Center is the DoD site
with comprehensive diagnostic capability for military beneficiaries.
Zoonotic Disease Considerations
Principal Animal Hosts: Dogs, wild canids