A 58-year-old coach driver from the central part of Sweden was generally in good health and took no regular medication, but more than 15 years ago he first noticed multiple, blue/red, slightly raised, non-itching and non-ulcerating skin changes on his lower abdomen, back, buttocks, and groin. Several years later similar skin changes appeared on his face, around his nostrils and on his earlobes. He had noted nocturnal sweats but no fever. Extensive investigations by specialists undertaken over the years led to no definitive diagnosis. Histological examination of bone marrow and liver biopsy specimens showed no remarkable features. Tests for syphilis, Borrelia sp, and mycobacteria were negative. In 1996, skin smears to detect leprosy were negative.
When he was referred to the Swedish Institute for Infectious Disease Control in October 1996, his titre of antibodies to leishmania was found to be high (1/270). He has never travelled outside Europe. The geographical exposure and discrete signs of visceral involvement suggested the probable cause was Leishmania infantum. Liposomal amphotericin B (AmBisome) was given intravenously over 14 days (total 25.5 mg per kg body weight, total 2780 mg). 10 months after treatment, his skin changes had healed and no further nocturnal sweats had been noted.
L. infantum, a species that mainly infects dogs in Europe, causes a visceral infection in children but can cause atypical cutaneous leishmaniasis. It appears that atypical slow-growing cutaneous leishmaniasis may occur in immunocompetent individuals in Europe. It could mean that there are many forms of L. infantum that induce diverse forms of disease and this newly described zymodeme may be rare or the diseases it causes may be unrecognised. The infection appears amenable to treatment but would probably have more serious consequences if untreated.
Montelius S, Maasho K, Pratlong F, Lebbad M, Gregory L, Akuffo H
The Lancet 1998; 352: 1438