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American Cutaneous Leishmaniasis in U.S. Travelers

Barbara L. Herwaldt, MD, MPH; Susan L. Stokes; and Dennis D. Juranek, DVM, MSc
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From the Centers for Disease Control and Prevention, Atlanta, Georgia. Requests for Reprints: Barbara L. Herwaldt, MD, MPH, Centers for Disease Control and Prevention, Parasitic Diseases Branch, 4770 Buford Highway NE, Atlanta, GA 30341-3724. Acknowledgments: The authors thank the many resourceful persons who helped to track down the travelers, as well as the travelers themselves, whose stories made the search worthwhile. The authors also thank Ralph T. Bryan, MD, Allen W. Hightower, MS, Hans O. Lobel, MD, Phyllis L. Moir, MA, Carol A. Pertowski, MD, and Francis J. Steurer, MS, for their contributions.

Copyright 2004 by the American College of Physicians

Ann Intern Med. 1993;118(10):779-784. doi:10.7326/0003-4819-118-10-199305150-00004
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Objective: To characterize the exposures and practices of U.S. travelers who acquired cutaneous leishmaniasis in the Americas and to highlight problems they encountered in seeking medical care from U.S. physicians.

Design: A retrospective review of Centers for Disease Control and Prevention Drug Service records and a telephone survey of patients.

Patients: Fifty-nine civilian U.S. travelers with American cutaneous leishmaniasis for whom the Drug Service released sodium stibogluconate between 1 January 1985 and 30 April 1990; 58 travelers (98%) were interviewed.

Main Measurements: Travel destination, exposure duration, knowledge about leishmaniasis, and time from noticing skin lesions to release of drug.

Results: Overall, travelers acquired leishmaniasis in as many as 14 countries; 33 of 59 travelers (56%) were infected in Mexico or Central America. Twenty-seven travelers (46%) were conducting field studies and 23 (39%) were tourists, visitors, or tour guides. At least 15 persons (26% of the 58 interviewed travelers) were in forested areas for 1 week or less; at least 6 of these persons had a maximum exposure of 2 days. Ten persons (17%) were home at least 1 month before they noticed skin lesions. Patients consulted from one to seven physicians (mean, 2.1 physicians) before leishmaniasis was diagnosed. Overall, the median time from noticing lesions to the release of drug was 112 days (range, 13 to 1022 days); however, the median was only 55 days for 13 patients (22%) unusually knowledgeable about leishmaniasis and was a maximum of 60 days for 16 patients (28%) (including 7 of the 13 unusually knowledgeable patients) who generally consulted physicians exceptionally knowledgeable about infectious and tropical diseases.

Conclusions: Travelers to forested areas in Central America and Texas and their physicians need to be educated about the risk for acquiring leishmaniasis even during short stays; effective preventive measures; and appropriate medical management.


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Figure 1.
Typical ulcerative lesion of American cutaneous leishmaniasis.

Photograph courtesy of Dr. Thomas R. Navin.

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Figure 2.
Countries in which study patients (n = 59) acquired American cutaneous leishmaniasis.

Information for two persons is not shown because of their extensive travel; one of these persons may have acquired leishmaniasis in one of three other countries: Nicaragua, El Salvador, or Ecuador. From 5 to 12 travelers were infected in Mexico, 4 to 14 in Belize, 3 to 12 in Guatemala, and possibly 1 in Honduras.

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Figure 3.
Locations of 84 skin lesions in 59 U.

S. travelers with American cutaneous leishmaniasis. The mean number of lesions per person was 1.4 (range, 1 to 8 lesions).

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Figure 4.
Distributions (shown in box plots) of the numbers of days from first awareness of lesions to various events among U.

S. travelers with American cutaneous leishmaniasis. For each interval, time zero is when skin lesions were first noticed; minimum, median, and maximum numbers of days to various events are shown, as are numbers of days for the lower and upper quartiles of patients. Numbers of patients for whom the durations of the intervals were estimable are shown in parentheses.

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