To treat or not to treat?

Paediatric dermatology

Dr. Emmanuelle Bourrat

Saint-Louis Hospital

The clinical case
Now it's your turn!
Co-prescription and advice

Clinical case presentation

Fifteen days after returning from a two-month stay in Senegal without any particular incident, this 6-year-old girl developed three crusted lesions on her face. She was treated with topical antibiotics under the assumption of impetigo, but this did not prevent the lesions from progressing.

She did not see a dermatologist until three months later, presenting with mid-facial papular and keratotic plaques, with peripheral progression in the form of small satellite papules. There was no mucosal involvement (nose, mouth) or satellite lymphadenopathy.

Your turn

What is your diagnosis?

Select 1 answer(s) from the following choices:

Methicillin-resistant Staphylococcus aureus impetigo

Yaws

Leishmaniasis due to Leishmania major

Leishmaniasis due to Leishmania braziliensis

Wrong answer!

Good answer!

Selected diagnosis

Direct examination of the parasitological sample confirmed the diagnosis of leishmaniasis in less than 24 hours, with secondary identification of Leishmania major by PCR, consistent with the patient's clinical picture and geographical origin.

The problem here was not so much diagnostic as therapeutic, given the patient's age and the location and number of lesions. The case was therefore discussed with a national leishmaniasis expert center, with the following conclusions:

Meglumine antimoniate: this treatment, which has marketing authorization for leishmaniasis, is administered by daily intramuscular injection or intralesionally. Both techniques seem difficult to accept in a child, given the multiple lesions located on the face.
Cryotherapy is not an option, given the size and number of lesions.
Aminoglycoside cream (paromomycin) is currently not readily available in France.
Other alternatives under evaluation (without marketing authorization) are fluconazole, itraconazole, liposomal amphotericin B and miltefosine.

Explanation of wrong answers

Methicillin-resistant Staphylococcus aureus impetigo is common in North America but can also occur in Africa. This type of impetigo will therefore be resistant to the first-line empirical antibiotic therapy of amoxicillin-clavulanate, but in this case would rapidly spread across the entire skin surface through autoinoculation. Moreover, the papule-like elementary lesion is more suggestive of a granulomatous condition.
Yaws, a non-venereal treponematosis caused by Treponema pallidum, develops in three stages, with ulcerated or crusted lesions in the primary (chancre) and secondary (pianomas) stages. This tropical dermatosis is very rarely encountered in children outside endemic countries (tropical and equatorial zones).
Leishmaniasis due to Leishmania braziliensis is a cutaneous or mucocutaneous leishmaniasis that does not tend to heal spontaneously and may have a locoregional deep progression with cartilaginous and mucosal involvement, which accounts for its severity. It has been described only in the New World, mainly South America.

Treatment

The child was re-examined one month later, after diagnosis, to discuss the various treatment options with the parents. The three lesions had completely regressed, and we decided to postpone any further treatment. Dyschromic and cribriform scars remain, however, which could perhaps have been avoided with an earlier diagnosis and treatment.

Message from the expert

Old World childhood leishmaniases usually have a spontaneously favorable prognosis, but the duration of the course and the risk of scarring vary greatly from case to case. It is therefore strongly recommended to discuss the indication for treatment with an expert center when the lesions are highly conspicuous (face, areas exposed to view) or rapidly progressive.

The therapeutic choice (or decision to observe) will be determined by the species, the topography and number of lesions, their clinical course and the patient's age.

References

^{Andrés Uribe-Restrepo and col Interventions to treat cutaneous leishmaniasis in children: A systematic review PLoS Negl Trop Dis. 2018 Dec; 12(12)}

^{https://pubmed.ncbi.nlm.nih.gov/30550538/}