Dear Dr. Roach: Two months after our daughter and son-in-law came back from their honeymoon in Belize, they have sores that still will not heal. She has two sores on her hand; he has three on the right side of his body. After a biopsy, they have been diagnosed with Leishmaniasis. Their dermatologist is referring them to an infectious disease specialist. What can you tell us about this disease and its treatment?
L.R.O.
It sounds like they have localized cutaneous Leishmaniasis, which is caused by protozoa, a type of parasite. The most common one from Belize is Leishmania braziliensis. It is transmitted by the bite of a sandfly, a tiny and silent insect whose bites often go unrecognized. They are nocturnal
insects, so people who are out at nighttime are at risk.
Cutaneous Leishmaniasis causes nonhealing sores that begin a few weeks or months after the bite.
The sores usually are painless, and can change over time. Without treatment, they usually will heal slowly, with scarring. Treatment speeds healing, and can be topical treatments, including heat treatment, topical anti-parasitic drugs or injection therapy. Since it鈥檚 likely that your daughter and son-in-law have limited disease, they probably will be treated with topical treatments.
However, not everybody needs treatment. It鈥檚 more important to treat larger lesions and those in a cosmetically important area. I certainly agree with getting an expert involved early. The laboratory that makes the diagnosis also needs to be expert, since the exact species guides treatment, to a large extent. The Centers for Disease Control and Prevention and Walter Reed Hospital are known experts in this condition.
The most dangerous complication is when the parasite attacks the internal organs, especially the spleen, liver and bone marrow. Fortunately, this is very rare in travellers, and almost unheard of in Belize, as the species found in that country can only very rarely cause this complication, which also is called 鈥渒ala azar.鈥� Finally, your family members should be carefully evaluated for other parasitic diseases: When you see one, there may be another.
Dear Dr. Roach: I have a non-cancerous fibromatosis nodule above my collarbone. It is painful. I also have a history of Dupuytren鈥檚 contracture. Could this be on a nerve, causing the pain?
C.V.
鈥淔ibromatosis鈥� is a nonspecific term for a tumour of connective tissue.
Dupuytren's contracture also is caused by fibrous tissue, in this specific instance in the hand, so it's possible your tumour above the collarbone could be related.
Indeed, any kind of tumour can press against nerves and cause pain. The pain from nerve damage usually is described as 鈥渂urning,鈥� 鈥減ins-and-needles鈥� or 鈥渟harp,鈥� so the quality of pain can give a clue to its underlying source.
Some tumours, such as desmoid tumors, are not cancerous, but can invade locally, damaging nerve cells; fortunately, the pathology report you sent shows that this type of tumour is unlikely.
Treatment options include medicine, surgery and possibly radiation.
Most people get partial relief from medication: Pain from a neuropathy (this term just means any damage to a nerve) usually can be reduced by half or more with medication, often medicines used for seizures (like gabapentin) or depression (like amitriptyline), even though the person has no seizures or depression. Surgery or radiation may be appropriate to consider for people with large tumours, especially if they are clearly pressing on a nerve.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected].
