Cutaneous Leishmaniasis (“Baghdad Boil”)

A 33-year-old active-duty soldier who had been in Iraq for 6 months presented with a depressed lesion on his left lateral elbow of several months’ duration. It was neither healing nor enlarging. (The yellowish tint to the skin in the photograph was from a topical iodine solution.) In Iraq, he was a truck driver and often slept in the cab of his vehicle. He rarely applied insect repellent to his exposed skin, and his uniforms were not treated with permethrin. CPT Kenneth Brooks, PA-C, of Camp As Sayliyah, Doha, Qatar, made a presumptive diagnosis of leishmaniasis based on the clinical appearance of the lesion. A biopsy specimen was sent to Walter Reed Army Institute for Research, where polymerase chain reaction assay confirmed the diagnosis. The parasitic disease leishmaniasis has been a constant problem for soldiers in Iraq. The sandflies of the Phlebotomus and Lutzomyia species are small enough to crawl through the mesh of most mosquito nets. In cutaneous leishmaniasis, the sandfly bite develops into a sharply demarcated, ulcerated lesion about 2 cm in diameter. Depending on the immune status of the host and the specific type of leishmaniasis, the disease may progress to mucocutaneous leishmaniasis. Most of the cases of leishmaniasis in Iraq are caused by Leishmania major; in immunocompetent patients, the lesions heal spontaneously and leave an indented scar. For the past 50 years, the only effective drug for cutaneous leishmaniasis has been the pentavalent antimonial compound sodium stibogluconate. Although it is available in Great Britain, this drug is approved only as an investigational new drug through the FDA for military personnel and through the CDC for civilians in the United States. Prevention is preferable to treatment. Insect nets treated with repellents or insecticides have reduced the incidence of leishmaniasis by as much as 50% in some areas. The military stresses personal protective measures: a uniform treated with permethrin should be worn with sleeves down, and exposed skin should be protected with an effective repellent, such as deet. Anecdotal evidence suggests that sandflies prefer still air for flying; therefore, a slight breeze generated by a fan may be adequate to keep them away. At the patient’s follow-up visit 3 months later, the lesion has healed but left marked inflammation, and the superficial veins appear more dilated than they were on his first visit. He has been referred to Walter Reed Army Medical Center for ongoing evaluation and treatment.