A case of imported Leishmania infantum cutaneous leishmaniasis; an unusual presentation occurring 19 years after travel

Background: Leishmania infantum is a flagellated protozoan parasite that is able to parasitize blood and tissue. Leishmania species cause a spectrum of clinical disease with cutaneous, visceral or mucosal involvement. L. infantum is recognised as a cause of visceral leishmaniasis (VL) and is less commonly reported as a cause of cutaneous leishmaniasis (CL) from countries around the Mediterranean basin. This is the first report of imported L. infantum CL to Australia and is remarkable for a 19 year period between the patient's exposure to an endemic region, and the manifestation of symptoms. Case presentation: A 76 year old Italian-born man presented to our institution with a non-healing lesion over his upper lip, abutting his nasal mucosa. The patient had travelled to Italy, an endemic area for L. infantum 19 years earlier but had resided in Australia, a non-endemic area since. Histopathology performed on a biopsy of the lesion demonstrated findings consistent with CL. A species specific polymerase chain reaction (PCR) performed on the tissue detected L. infantum. The patient had complete clinical recovery following treatment with Liposomal amphotericin B at a dose of 3 mg/kg for five days followed by a subsequent 3 mg/kg dose at day ten. Conclusions: L. infantum should be recognised as a cause of imported CL in returned travellers from the Mediterranean. In this case, the incubation period for L. infantum CL was at least 19 years. This case adds to the described spectrum of clinical presentations of leishmaniasis and supports the theory of parasite persistence underlying natural immunity and recurrence of disease. Clinicians should consider L. infantum CL in the differential diagnosis of a non-healing skin lesion in any patient who reports travel to the Mediterranean, even when travel occurred several years before clinical presentation.