Travel Medicine and Infectious Disease xxx (2017) 1e2 Contents lists available at ScienceDirect Travel Medicine and Infectious Disease journal homepage: www.elsevierhealth.com/journals/tmid Cutaneous leishmaniasis in immigrant workers returning to Bangladesh e An emerging problem Keywords: Cutaneous leishmaniasis Bangladesh Immigrant Dear Editor Visceral leishmaniasis is endemic in Bangladesh [1]. Cutaneous leishmaniasis (CL), on the other hand, is rare in Bangladesh although there are quite a few cases of post kala-azar dermal leishmaniasis [2]. CL is frequent in all Mediterranean countries, presenting as a single (and infrequently as a multiple) localized scabby cutaneous lesion. The disease is occasionally self-limiting but it usually presents as a chronic infection or with chronic evolution, which requires local or systemic anti leishmanial drugs [3]. Leishmaniasis (visceral and cutaneous) is seldom described as a disease which is imported through travel or immigration from an endemic region, with only a limited number of cases being reported to date [4,5]. However, in the last few decades, the number of workers travelling to the Middle East from Bangladesh has increased, causing potential exposure to CL [4]. Therefore, the potential to see imported cases among immigrant returners poses a threat to the hopes of eliminating Kala-azar in Bangladesh. Because the presentation of CL mimics disease such as tuberculosis, anthrax, fungal infection and skin carcinoma this creates a diagnostic problem for among our unaware physicians who may have little knowledge of this disease. This could lead to inappropriate management of the condition. In order to address this new challenge, a better understanding and awareness of imported CL is urgently needed. To this end, we aim to write to the editor to report three cases of CL imported to Bangladesh from Saudi Arabia. 1. The cases Three male patients (aged 34e45 years) returning from Abha province of Saudi Arabia, attended our clinic. They came due to the appearance and the progressive extension of velvety erythematous lesion and progressive ulceration over different parts of the body, e.g. nose (Fig. 1), fore-arm, fingers, cheeks, hands and neck lasting for two to three months. Initially, lesions had a papular appearance, later extending to adjacent tissues evolving into infiltrated granulomatous appearance, with an indurated bottom, and sharp border and having sero-haematic discharge. Some lesions enlarged with a central crater covered with crust and serous discharge. There was no history of fever, anorexia, weight loss, lymphadenopathy or abdominal swelling. All the patients reported several bites by unspecified insects. One patient had been diagnosed with CL in Saudi Arabia and treatment with Sodium stibogluconate was instituted without any improvement. Another was treated with miltefosine initially, but the treatment was had no effect. Direct microscopy examination of slit skin smear by Giemsa stain showed numerous amastigote forms of leishmania spp in all the three cases. Routine blood tests and other microbiological workouts, such as acid-fast bacilli, bacillus anthracis and fungi were done and found to be negative. We gave Inj. Liposomal amphotericin-B (AmBisome) 5mg/kg/day and continued for every alternate day for six doses without any unwanted side-effect. During therapy, the progressive amelioration of lesions was observed. One month later, during follow-up, the partial disappearance of granulomatous, ulcerated and indurated dermal and subcutaneous infiltrates was also noted but cutaneous dyschromia at edges were still evident. Further clinical improvement was observed during the subsequent follow ups. CL is the most common form of leishmaniasis and one of the ten most frequent skin diseases contracted after travelling [6]. Worldwide estimates suggest that there are 1.5e2.0 million new cases and about 350 million at risk of infection [4]. Only L. tropica is anthroponotic. The complex eco-epidemiological web which characterizes leishmaniasis is not yet well understood. Meanwhile endemic countries can offer a great deal of information from data gathered from case reports of their specific geographical area and from foreign endemic areas. Because of the variety of Leishmania species and the existing geographical differences, leishmaniasis could be considered to be a polymorphous group of complex diseases each with a variety of clinical features, treatment options, and different prognoses. Thus not only medical personnel but also people from all walks of life should be aware of this disease. A high index of suspicion is necessary to diagnose this. Diagnosis can be confirmed by demonstrating LD bodies under direct microscopy from smear preparation. We were unable to confirm the exact species due to the limited laboratory facilities. Effective treatment of patients presenting with CL of various origins has yet to be determined. Evidence-based data on travelers are limited to a few studies and anecdotal reports. Investigations of military personnel and published experience among patients from endemic areas are not sufficient. Oral, as well as parenteral medications eg. sodium stibogluconate, liposomal amphotericin B, miltefosine amongst others, are currently available. Newer treatment modalities include cryotherapy, intra-lesional injection of sodium stibogluconate etc. But which treatment is the most effective and safest is yet to be decided. All of our cases were successfully treated with injectable liposomal amphotericin B at 5mg/kg/day every alternate day for six doses. It is important to mention that http://dx.doi.org/10.1016/j.tmaid.2017.05.013 1477-8939/© 2017 Elsevier Ltd. All rights reserved. Please cite this article in press as: Basher A, et al.Cutaneous leishmaniasis in immigrant workers returning to Bangladesh e An emerging problem, Travel Medicine and Infectious Disease (2017), http://dx.doi.org/10.1016/j.tmaid.2017.05.013 2 A. Basher et al. / Travel Medicine and Infectious Disease xxx (2017) 1e2 College Hospital in Chittagong, Bangladesh and Surya kanta Kalaazar Research Centre which is the infectious disease wing of Mymensingh Medical College Hospital in Mymensingh, Bangladesh. We also thanks to Mrs. Rebecca Allen, Peter Medawar Building for Pathogen Research of University of Oxford for revising the draft. References Fig. 1. Velvety erythematous lesion over the nose. two patients had a failed treatment experience with injection of sodium stibogluconate (Pentosam; 20 mg/kg/day for 20e28 days) and oral miltefosine (100 mg daily on divided dose for 28 days) respectively. [1] World Health Organization for South East Asia Region. Status of Kala-Azar in Bangladesh, Bhutan, India and Nepal: a regional review update. New Delhi. Available from: http://www.Searo.Who.Int/Linkfiles/Kala_Azar_Kala Status2008webpagefeb2009.Pdf (Cited On 10 Aug 2016). [2] Basher A, Nath P, Nabi SG, Selim S, Rahman MF, Sutradhar SR, et al. A study on health seeking behaviors of patients of post-Kala-Azar dermal leishmaniasis. Biomed Res Int 2015;2015:314543. http://dx.doi.org/10.1155/2015/314543. [3] Salam N, Al-Shaqha WM, Azzi A. Leishmaniasis in Middle East: incidence and epidemiology. PLoS Negl Trop Dis 2014 Oct;8(10):e3208. [4] Rahman H, Razzak MA, Chanda BC, Bhaskar KRH, Mondal D. Cutaneous leishmaniasis in a Saudi immigrant worker: a case report. J Health Popul Nutr 2014 Jun;32(2):372e6.  G, Mateo C, Gaya V, Uso  J, Mínguez C, Roca B, et al. Admissions for im[5] Girone ported and non-imported parasitic diseases at a General Hospital in Spain: a retrospective analysis. Travel Med Infect Dis 2015 Jul-Aug;13(4):322e8. [6] Scope A, Trau H, Bakon M, Yarom N, Nasereddin A, Schwartz E. Imported mucosal leishmaniasis in a traveler. Clin Infect Dis 2003 Sep 15;37(6):e83e7. 2. Conclusion Our experience shows liposomal amphotericin B could be an effective treatment option for CL; though the number of patients enrolled is limited and we still need to follow up the cases to determine whether there was any relapse. It would be interesting to see whether the combination with miltefosine provides a better outcome. The imported cases of CL may threaten the success of the Kala-azar elimination program in of Bangladesh. Conflict of interest None. Funding None. Ethical consideration Written informed consent was taken from the patients for publishing their history and pictures. Utmost respect and sympathy were shown to the patients during the course of treatment. Ariful Basher, Registrar, Proggananda Nath, Medical Officer Infectious and Tropical Medicine Mymensingh Medical College & Hospital, Mymensingh, Bangladesh Tonmoy Dey, Medical Officer Dapunia Union Health Sub-center, Sadar Upazila, Mymensingh, Bangladesh Abdullah Abu Sayeed, Consultant Chitagong Medical College Hospital, Chittagong, Bangladesh M. Abul Faiz, Professor & chairman Dev-Care Foundation, Dhaka, Bangladesh Fazle Rabbi Chowdhury, D.Phil. in Clinical Medicine Candidate* Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, University of Oxford, UK Junior Consultant, Medicine, OSD, Health Directorate, Dhaka, Bangladesh * Corresponding author. Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, University of Oxford, UK. E-mail address: fazle.chowdhury@ndm.ox.ac.uk (F.R. Chowdhury). Acknowledgement We give special thanks to authorities of Chittagong Medical 29 April 2017 Available online xxx Please cite this article in press as: Basher A, et al.Cutaneous leishmaniasis in immigrant workers returning to Bangladesh e An emerging problem, Travel Medicine and Infectious Disease (2017), http://dx.doi.org/10.1016/j.tmaid.2017.05.013