First case of typical Old World cutaneous leishmaniasis treated with miltefosine.

A 26-year-old man presented to our clinic for advice on treatment options regarding cutaneous leishmaniasis (CL) with multiple lesions. The biopsy revealed Leishmania amastigotes; Leishmania major was identified by polymerase chain reaction (PCR).(11 )Leishmania serology (indirect immunofluorescence test) was positive at 1 : 160 (normal, < or = 1 : 40). Ten weeks earlier, the patient had spent a 1-week biking holiday in central Tunisia. Two weeks after returning to Germany, he noticed the flaring up of multiple insect bites (> 40) contracted in Tunisia on both arms. The lesions increased in size and axillary lymph node enlargement occurred. Some of the nodular lesions disappeared spontaneously and some increased in size and showed central ulceration. When we first saw the patient, he had six lesions on his right arm and one on his left arm. The largest lesion was on the dorsum of the right hand (Fig. 1) and showed an indurated edge and central ulceration. Before starting systemic treatment, the patient decided to wait a few weeks in case spontaneous improvement occurred. However, 8 weeks later, the ulceration had further increased in size (Fig. 2) from a diameter of 2 cm initially to a diameter of 5 cm. Regional lymphatic spread with palpable nodules along the adjacent lymphatic vessel had occurred. With the patient's informed consent, treatment with oral miltefosine, according to his body weight of 96 kg, was started at 50 mg three times daily for 28 days. The treatment was well tolerated without any subjective side-effects reported. Liver enzymes, serum creatinine, and urea were monitored during treatment. There was a mild increase in liver enzymes during the third week of treatment: aspartate aminotransferase (AST), 49 U/L (normal, < 35 U/L); alanine aminotransferase (ALT), 107 U/L (normal, < 45 U/L); this resolved spontaneously. Ten days after completion of treatment, the rolled edge had disappeared and the central ulcer had almost healed (Fig. 3). Figure 4 shows the lesion 5 months after completion of treatment.