Internal Medicine

0521779407-10 CUNY1086/Karliner 0 521 77940 7 June 6, 2007 17:44

Legionella Infections Leishmaniasis, Cutaneous 889

macrolides; in severely ill patients, some recommend addition of

rifampin to above regimens; anecdotal case reports of success with

imipenem, trimethoprim-sulfamethoxazole and clindamycin

■Duration of therapy 10–14 days in immunocompetent patients and

3 weeks in immunosuppressed

■Initial therapy usually parenteral, with switch to oral drugs after clin-

ical improvement

follow-up

■Clinical improvement in 3–5 days

■Chest x-ray may worsen initially, even with appropriate therapy and

clinical improvement; may take months for complete resolution of

infiltrates

complications and prognosis

■Mortality <5% in immunocompetent and up to 30% in immunocom-

promised

■Superheating water (140◦F) eliminates organism.

LEISHMANIASIS, CUTANEOUS

J. GORDON FRIERSON, MD

history & physical

History

■Exposure: bite of phlebotomine fly while in endemic area. The dis-

order is generally divided into Old World and New World disease.

Causative agents of Old World disease are Leishmania tropica (found

in Mediterranean countries, Middle East, SW Asia), L major (found in

the Middle East, Central Asia, Indian subcontinent, tropical Africa),

L aethiopica (found in Ethiopia, Kenya). Causative agents of New

World disease are the L mexicana complex (L mexicana, L amazo-

nensis, L venezuelensis), and the L braziliensis complex (L brazilien-

sis, L panamensis, L guyanensis, L peruviana), all found in Central

America and tropical parts of South American countries.

Signs & Symptoms

■A papule at the site of the fly bite, sometimes at a site of trauma

(puncture wound, etc.) develops and gradually ulcerates. Ulcers

are single or multiple, have raised edges, are only mildly painful.

Local adenopathy is common; sometimes nodules occur along