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Complicated cutaneous leishmaniasis caused by an imported case of Leishmania tropica in Japan: a case report

Abstract

Background

Leishmaniasis is not endemic in Japan, and imported cases are rare. However, there are increasing concerns regarding imported cases of cutaneous leishmaniasis from endemic countries to Japan. This report describes a case of imported cutaneous leishmaniasis that was diagnosed and treated in Japan.

Case presentation

A 53-year-old Pakistani man presented with skin lesions on both malleoli of his right ankle and the dorsum of the left foot. The skin lesions manifested as erythematous nodules surrounding an ulcer in the center of the lesion. The lesions of the malleoli of his right ankle each measured 3 × 3 cm, and the lesion on the top of his left foot measured 5 × 4 cm. He had been living and working in Japan but had a history of a visit to Pakistan for about 2 months in 2018. The skin lesions were biopsied. Giemsa and hematoxylin and eosin staining of biopsy samples showed amastigotes of Leishmania in macrophages, and the presence of Leishmania was confirmed by skin tissue culture. Polymerase chain reaction using biopsy specimens identified Leishmania parasites, and DNA sequence analysis revealed that the species was Leishmania tropica. The patient was treated with intravenous liposomal amphotericin B for 6 days. The erythema disappeared, and the erythematous nodules resolved within 3 weeks.

Conclusion

This is the first report of imported cutaneous leishmaniasis caused by L. tropica from Pakistan, and it is interesting that all three testing modalities showed positive results in this case.

Background

Leishmaniasis is a major global health problem. An estimated 0.7–1 million new cases of leishmaniasis are reported per year from approximately 100 endemic countries [1]. Leishmaniasis is a vector-borne parasitic disease caused by protozoa of the genus Leishmania and is transmitted between mammalian hosts by female sandflies [2, 3]. Leishmaniasis is classified into three main clinical syndromes: cutaneous leishmaniasis (CL), mucocutaneous leishmaniasis, and visceral leishmaniasis [4]. The most predominant form of leishmaniasis is CL, with an estimated global incidence of 600,000 to one million cases each year [5]. CL is not life-threatening but has a profound socioeconomic impact due to the stigmatization of infected and cured individuals, as the disease may leave residual disfiguring scars [6, 7]. Leishmaniasis is not endemic in Japan, and there have been few reports of imported infections; approximately 27 imported cases were reported from 1950 to 1995 [8,9,10], and only 3 imported CL cases were reported in a few articles since 1996 [11,12,13]. However, there are increasing concerns of imported cases of CL from endemic countries to Japan [11]. We report a case of CL caused by Leishmania tropica in an adult male who presented to the Hiroshima University Hospital in Hiroshima, Japan. The infection was confirmed by immunohistochemistry, skin tissue culture, and polymerase chain reaction (PCR).

Case presentation

A 53-year-old man from Pakistan presented to the Hiroshima University Hospital in Japan in January 2019 with persistent skin lesions of both malleoli of his right ankle and the dorsum of his left foot. The immunohistochemistry of a skin biopsy, performed in November 2018 at another hospital in Japan, had suggested leishmaniasis. The lesions and itching had appeared in November 2018 and did not respond to gentamicin ointment. Three years previously, he had been living and working in Japan but returned to Khyber Pakhtunkhwa province, Pakistan, which is an endemic area for CL caused by L. tropica and Leishmania major [14,15,16] for about 2 months (August–September) in 2018. The skin lesions manifested as erythematous nodules surrounding an ulcer in the center of the lesion. The lesions on the malleoli of his right ankle each measured 3 × 3 cm, and the lesion on the dorsum of his left foot measured 5 × 4 cm (Fig. 1a–c). He requested further tests for an accurate diagnosis of his skin disease. We performed a punch biopsy of each skin lesion and collected the exudate from the skin lesions. Giemsa staining of the exudate and hematoxylin and eosin (HE) staining of the skin biopsy tissue demonstrated Leishmania amastigotes in macrophages on histological examination (Fig. 2a–b). Leishmania promastigotes were detected 2 weeks later in the culture of a skin punch biopsy specimen that had been preserved in saline and then transferred to medium 199 supplemented with 10% heat-inactivated fetal bovine serum (Fig. 2c). Immunohistochemical staining using the C11C antibody (a monoclonal antibody against Leishmania peroxiredoxin/thiol-specific antigen) [17] also detected positive cells in the skin lesion (Fig. 2d). For the molecular diagnosis of Leishmania infection, DNA was extracted from the skin biopsy sample using a DNeasy Blood and Tissue Kit (QIAGEN, Tokyo, Japan). We performed PCR with the DNA samples to identify the Leishmania parasite mini-exon gene [18] and detected products of expected sizes on agarose gel electrophoresis. The causative species was identified as either L. major or L. tropica (Fig. 3). The amplified DNA fragments were size selected from agarose gels and cloned into the vector pCR2.1-TOPP, continuously subjected to sequencing. The phylogenetic tree was constructed based on the 368-nt nucleotide sequences by the maximum likelihood method and Kimura two-parameter model using Molecular Evolutionary Genetics Analysis Version 10.2.2 (MEGA X) software [19]. The bootstrap scores were calculated for 1000 replicates (Fig. 4). The patient consented to all the specialized diagnostic tests, including DNA sequence analysis that was performed for species identification. Based on these findings, we diagnosed the lesions as CL caused by L. tropica and started treatment with intravenous liposomal amphotericin B (AmBisome, Dainippon Sumitomo Pharma, Osaka, Japan), which was administered intravenously daily for 6 days. The patient did not experience fever or fatigue or any other side effects during the course of treatment. Three weeks after starting treatment, the erythema disappeared, and the erythematous nodules resolved (Fig. 1d–f).

Fig. 1
figure1

Skin lesions at initial presentation (ac) and after treatment (df). Erythematous nodules with peripheral ridges and central ulceration located on the right medial malleolus (a), right lateral malleolus (b), and the top of the left foot (c). After treatment, the erythema has disappeared and the nodules on the right medial malleolus (d), right lateral malleolus (e), and top of the left foot (f) have resolved

Fig. 2
figure2

Appearance of the lesions on histology. Giemsa staining (a) and hematoxylin and eosin staining (b) of punch biopsy specimens show Leishmania amastigotes (arrowheads). Giemsa staining of the skin tissue culture shows Leishmania promastigotes (c). C11C antibody-positive cells in the patient’s skin lesion (d). All bars are 5 μm

Fig. 3
figure3

Polymerase chain reaction results. Amplified DNA extracted from a skin sample is positive (lane 1). The positive control samples with Leishmania tropica DNA, L. major DNA, and L. donovani DNA are shown in lanes 2, 3, and 4, respectively, and the negative control is shown in lane 5

Fig. 4
figure4

The phylogenetic tree. The phylogenetic tree was constructed based on the 368-nt nucleotide sequences by the maximum likelihood method and Kimura 2-parameter model

Discussion and conclusion

Leishmaniasis is endemic in many developing countries. One study found that CL represented 3.3% of skin lesions in 4594 returning travelers with travel-related skin disorders, worldwide [20]. Most of the returning travelers had traveled to Latin America, and 15% had become infected within 2 weeks of staying in an endemic country [20]. In Japan, there is currently no evidence of the presence of the species of sandfly that transmit leishmaniasis. Considering the ecology of sandflies, it is unlikely that sandflies will enter Japan with travelers and expand their habitat. Although the possibility of the disease spreading to Japan is low, notification of imported cases is necessary in the age of globalization.

The major causative parasite species of CL are L. major and L. tropica endemic to the Mediterranean Basin, the Middle East, the Horn of Africa, and the Indian subcontinent [21]. In Pakistan, CL is caused by either L. major or L. tropica [22], as in this case. Leishmaniasis may be underdiagnosed or overdiagnosed, and unnecessary treatment has been administered in some cases in Pakistan [23].

Nodular lesions of CL are often mistaken for furuncles [1]; therefore, the diagnosis should be made based on careful examination and the presence of a typical lesion in conjunction with an appropriate history of exposure [23].

Parasitological confirmation should be sought preferably by confirming the growth of the organism in culture [12]. A full-thickness biopsy from an infiltrated margin of the lesion is useful for histological examination and culture [23]. Specimens collected by biopsy are stained using HE and Giemsa stains and examined for Leishmania amastigotes in the skin tissue [24]. However, it is not always possible to make the diagnosis based on a skin biopsy in clinical practice. The parasite may not be detected even by the most adequate methods [23]. PCR testing is more sensitive than immunohistochemistry and culture and is useful for confirming the diagnosis [23]. In our case, PCR targeting a mini-exon gene could not distinguish between L. major and L. tropica as the causative species, and hence, we performed DNA sequencing and determined that the causative organism was L. tropica. Serology may not be helpful for the diagnosis of CL because antibodies tend to be undetectable or present in low titers [23]; however, serological testing can be useful for initial screening [25].

The treatment of CL involves either intralesional injection of 8.5% meglumine antimonite (Glucantime) or intravenous liposomal amphotericin B [26]. Liposomal amphotericin B was approved for the treatment of leishmaniasis in June 2009 in Japan. As the patient had three skin lesions and was experiencing severe symptoms, we chose to use intravenous liposomal amphotericin B (3 mg/kg, 250 mg/body, administered daily for 6 days) as recommended by the Japanese guideline (https://www.nettai.org).

In this case, Leishmania amastigotes were detected in HE- and Giemsa-stained skin biopsy specimens, and Leishmania promastigotes were detected by skin culture. In cases of CL, it is rare for all three testing modalities to be positive. This is the first report of imported CL caused by L. tropica from Pakistan and it contributes useful information on the most appropriate anti-leishmanial therapies for imported cases of CL.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Abbreviations

CL:

Cutaneous leishmaniasis

HE:

Hematoxylin and eosin

L. major :

Leishmania major

L. tropica :

Leishmania tropica

PCR:

Polymerase chain reaction

References

  1. 1.

    Burza S, Croft LS, Boelaert M. Leishmaniasis. Lancet. 2018;392:951–70. https://doi.org/10.1016/S0140-6736(18)31204-2.

    Article  PubMed  Google Scholar 

  2. 2.

    Talmi-Frank D, Kedem-Vaanunu N, King R, Kahila Bar-Gal G, Edery N, Jaffe CL, et al. Leishmania tropica infection in golden jackals and red foxes. Israel Emerg Infect Dis. 2010;16:1973–5. https://doi.org/10.3201/eid1612.100953.

    Article  PubMed  Google Scholar 

  3. 3.

    Labony SS, Begum N, Rima UK, Chowdhury GA, Hossain MZ, Habib MA, et al. Apply traditional and molecular protocols for the detection of carrier state of visceral leishmaniasis in black Bengal goat. J Agric Vet Sci. 2014;7:3–8. https://doi.org/10.9790/2380-07231318.

    Article  Google Scholar 

  4. 4.

    Masumoudi A, Hariz W, Marrkechi S, Amouri M, Turki H. Old World cutaneous leishmaniasis: diagnosis and treatment. J Dermatol Case Rep. 2013;2:31–41. https://doi.org/10.3315/jdcr.2013.1135.

    Article  Google Scholar 

  5. 5.

    Alvar J, Vélez ID, Bern C, Herrero M, Desjeux P, Cano J, et al. Leishmaniasis worldwide and global estimates of its incidence. PLoS One. 2012;7:e35671. https://doi.org/10.1371/journal.pone.0035671.

  6. 6.

    Bennis I, De Brouwere V, Belrhiti Z, Sahibi H, Boelaert M. Psychosocial burden of localised cutaneous Leishmaniasis: a scoping review. BMC Public Health. 2018;18:358. https://doi.org/10.1186/s12889-018-5260-9.

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Bailey F, Mondragon-Shem K, Haines LR, Olabi A, Alorfi A, Ruiz-Postigo JA, et al. Cutaneous leishmaniasis and co-morbid major depressive disorder: a systematic review with burden estimates. PLoS Negl Trop Dis. 2019;13:e0007092. https://doi.org/10.1371/journal.pntd.0007092.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Koichi N. Infectious Agents Surveillance Report, vol. 16; 1995. https://idsc.niid.go.jp/iasr/CD-ROM/records/16/18104.htm (in Japanese). Accessed 8 Jan 2021

    Google Scholar 

  9. 9.

    Ogino S, Sakai S, Sato T, Inoki S. A case of American leishmaniasis. Otolaryngology. 1976;48:521–3 Translated from Japanese.

    Google Scholar 

  10. 10.

    Shirabe S, Su W, Soda T. A case of American leishmaniasis. Otol Fukuoka. 26:580–3. https://doi.org/10.11334/jibi1954.26.3_580.

  11. 11.

    Ito K, Takahara M, Ito M, Oshiro M, Takahashi K, Uezato H, Imafuku S. An imported case of cutaneous leishmaniasis caused by Leishmania (Leishmania) donovani in Japan. J Dermatol. 2014;41:926–8. https://doi.org/10.1111/1346-8138.12609.

    Article  PubMed  Google Scholar 

  12. 12.

    Uchida S, Oiso N, Sanjoba C, Matsumoto Y, Yanagihara S, Annoura T, et al. Cutaneous leishmaniasis caused by Leishmania tropica in Israel. J Dermatol. 2018;45:e240–1. https://doi.org/10.1111/1346-8138.14300.

    Article  PubMed  Google Scholar 

  13. 13.

    Imai K, Tarumoto N, Amo K, Takahashi M, Sakamoto N, Kosaka A, et al. Non-invasive diagnosis of cutaneous leishmaniasis by the direct boil loop-mediated isothermal amplification method and MinION™ nanopore sequencing. Parasitol Int. 2018;67:34–7. https://doi.org/10.1016/j.parint.2017.03.001.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Ayaz MM, Nazir MM, Ullah N, Zaman A, Akbar A, Zeeshan M, et al. Cutaneous leishmaniasis in the Metropolitan city of Multan, Pakistan, a neglected tropical disease. J Med Entomol. 2018;55:1040–2. https://doi.org/10.1093/jme/tjy003.

    Article  PubMed  Google Scholar 

  15. 15.

    Hussain M, Munir S, Jamal MA, Ayaz S, Akhoundi M, Mohamed K. Epidemic outbreak of anthroponotic cutaneous leishmaniasis in Kohat District, Khyber Pakhtunkhwa. Pakistan. Acta Trop. 2017;172:147–55. https://doi.org/10.1016/j.actatropica.2017.04.035.

    Article  PubMed  Google Scholar 

  16. 16.

    Hussain M, Munir S, Ayaz S, Khattak BU, Khan TA, Muhammad N, et al. First report on molecular characterization of Leishmania species from cutaneous leishmaniasis patients in southern Khyber Pakhtunkhwa province of Pakistan. Asian Pac J Trop Med. 2017;10:718–21. https://doi.org/10.1016/j.apjtm.2017.07.015.

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Musa MA, Nakamura R, Hena A, Varikuti S, Nakhasi H, Goto Y, et al. Lymphocytes influence Leishmania major pathogenesis in a strain-dependent manner. PLoS Negl Trop Dis. 2019;13. https://doi.org/10.1371/journal.pntd.0007865.

  18. 18.

    Katakura K, Kawazu S, Sanjoba C, Naya T, Matsumoto Y, Ito M, et al. Leishmania mini-exon genes for molecular epidemiology of leishmaniasis in China and Ecuador. Tokai J Exp Clin Med. 1998;23:393–9.

    CAS  PubMed  Google Scholar 

  19. 19.

    Kumar S, Stecher G, Li M, Knyaz C, Tamura K, Mega X. Molecular Evolutionary Genetics Analysis across computing platforms. Mol Biol Evol. 2018;35:1547–9. https://doi.org/10.1093/molbev/msy096.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Lederman ER, Weld LH, Elyazar IR, von Sonnenburg F, Loutan L, Schwartz E, et al. Dermatologic conditions of the ill returned traveler: an analysis from the GeoSentinel Surveillance Network. Int J Infect Dis. 2008;12:593–602. https://doi.org/10.1016/j.ijid.2007.12.008.

    Article  PubMed  Google Scholar 

  21. 21.

    de Vries HJ, Reedijik SH, Schallig HD. Cutaneous leishmaniasis: recent developments in diagnosis and management. Am J Clin Dermatol. 2015;16:99–109. https://doi.org/10.1007/s40257-015-0114-z.

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Rajpar GM, Khan MA, Hafiz A. Laboratory investigation of cutaneous leishmaniasis in Karachi. J Pak Med Assoc. 1983;33:248–50.

    CAS  PubMed  Google Scholar 

  23. 23.

    Khan SJ, Muneeb S. Cutaneous leishmaniasis in Pakistan. Dermatol Online J. 2005;11:4.

    PubMed  Google Scholar 

  24. 24.

    Kubba R, Al-Gindan Y, El-Hassan AM, Omer AH. Clinical diagnosis of cutaneous leishmaniasis (oriental sore). J Am Acad Derm. 1987;16:1183–9. https://doi.org/10.1016/s0190-9622(87)70155-8.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Okumura Y, Yamauchi A, Nagano I, Itoh M, Hagiwara K, Takahashi K, et al. A case of mucocutaneous leishmaniasis diagnosed by serology. J Dermatol. 2014;41:739–42. https://doi.org/10.1111/1346-8138.12564.

    Article  PubMed  Google Scholar 

  26. 26.

    Ono M, Takahashi K, Taira K, Uezato H, Takamura S, Izaki S. Cutaneous leishmaniasis in a Japanese returnee from West Africa successfully treated with liposomal amphotericin B. J Dermatol. 2011;38:1062–5. https://doi.org/10.1111/j.1346-8138.2011.01270.x.

    CAS  Article  PubMed  Google Scholar 

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Contributions

K.I. and K.F. contributed to the conception and design of this report; C.S. and Y.G. performed the microbiological analysis; K.O., N.S., M.H., Y.M., and H.O. critically reviewed the manuscript and supervised the research. All the authors read and approved the final manuscript.

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Correspondence to Hiroyuki Kitano.

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Kitano, H., Sanjoba, C., Goto, Y. et al. Complicated cutaneous leishmaniasis caused by an imported case of Leishmania tropica in Japan: a case report. Trop Med Health 49, 20 (2021). https://doi.org/10.1186/s41182-021-00312-4

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Keywords

  • Cutaneous leishmaniasis
  • Japan
  • Skin diseases
  • Pakistan
  • Imported diseases
  • Leishmania tropica