[Skip to Content]
[Skip to Content Landing]

Incidence of Endemic Human Cutaneous Leishmaniasis in the United States

Educational Objective
To recognize the ability of cutaneous leishmaniasis to be acquired endemically in the United States.
1 Credit CME
Key Points

Question  Is human cutaneous leishmaniasis endemic in North America?

Findings  This cross-sectional observational study identified 41 novel cases of endemic cutaneous leishmaniasis occurring in humans since 2007, mostly in Texas. Endemic cases represented 59% of all cases identified.

Meaning  Human cutaneous leishmaniasis appears to be endemic in the United States and is acquired endemically more frequently than it is via travel, which argues in favor of making it a federally reportable disease.

Abstract

Importance  Leishmaniasis is recognized as an endemic human disease in Africa, the Middle East, Asia, and South America. Yet despite case reports of endemic human leishmaniasis in the United States, and well-documented occurrences of disease in various animal vectors and reservoirs, the endemicity of leishmaniasis in North America has not yet been established. Moreover, leishmaniasis is not a federally reportable disease in the United States. Clinical awareness of endemic disease therefore remains low, with North American physicians considering leishmaniasis a tropical disease.

Objective  To assess the endemicity of human leishmaniasis in the United States.

Design, Setting, and Participants  This cross-sectional multicenter observational study reviewed cases of human leishmaniasis occurring in the United States from 2007 through 2017. Previously diagnosed, deidentified cases of leishmaniasis were reported by the institutions of the authors and acknowledged contributors, as well as the Texas Department of State Health Services. Cases of leishmaniasis were identified by searching by disease name (leishmaniasis) or International Classification of Diseases, 9th and 10th Revisions diagnosis codes in the respective laboratory information systems.

Exposures  Via examination of deidentified demographics, cases of leishmaniasis were classified as one of the following: (1) documentation of no history of travel outside of the United States within 10 years; (2) positive history of travel outside of the United States within 10 years; or (3) unknown or no documentation of travel history.

Main Outcomes and Measures  Cases of leishmaniasis were considered endemic if identified in patients with documentation of no travel history outside of the United States within 10 years.

Results  Of the 69 novel cases of human cutaneous leishmaniasis identified in this study, 41 (59%) were endemic; the median age at diagnosis was 61 years (range, 3-89 years), and 28 (68%) of the endemic cases occurred in female patients. Twenty-two (32%) cases had documentation of Leishmania speciation performed by polymerase chain reaction, and in 100% of these cases the infectious organism was identified as Leishmania mexicana.

Conclusions and Relevance  Human cutaneous leishmaniasis is endemic in the United States, and, at least regionally, is acquired endemically more frequently than it is via travel. Our data argue in favor of making leishmaniasis a federally reportable disease and may have substantial implications on North American public health initiatives, with climate models predicting the number of citizens exposed to leishmaniasis will double by 2080.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Corresponding Author: Bridget E. McIlwee, DO, ProPath, 1355 River Bend Dr, Dallas, TX 75247 (bridget.mcilwee@gmail.com).

Accepted for Publication: May 15, 2018.

Published Online: July 25, 2018. doi:10.1001/jamadermatol.2018.2133

Author Contributions: Drs McIlwee and Hosler had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: McIlwee.

Administrative, technical, or material support: McIlwee.

Study supervision: Weis, Hosler.

Conflict of Interest Disclosures: None reported.

Additional Contributions: The authors gratefully acknowledge Joseph Susa, DO, and Pam Seward at Cockerell Dermatopathology (Dallas, Texas), Renata Joffe, MD, and Laurel Nowden at Miraca Life Sciences (now Inform Diagnostics; Irving, Texas), and Eric Fonken, DVM, at the Texas Department of State Health Services (Austin, Texas) for their assistance in curating data and maintaining compliance with institutional review board–approved HIPAA requirements. They were not compensated for their contributions.

References
1.
Boelaert  M, Sundar  S. Leishmaniasis. In: Farrar  J, ed.  Manson’s Tropical Infectious Diseases. 23rd ed. Philadelphia, PA: Elsevier Inc; 2014:631-651. doi:10.1016/B978-0-7020-5101-2.00048-0
2.
González  C, Wang  O, Strutz  SE, González-Salazar  C, Sánchez-Cordero  V, Sarkar  S.  Climate change and risk of leishmaniasis in north america: predictions from ecological niche models of vector and reservoir species.  PLoS Negl Trop Dis. 2010;4(1):e585. doi:10.1371/journal.pntd.0000585PubMedGoogle ScholarCrossref
3.
Kerr  SF, McHugh  CP, Dronen  NO  Jr.  Leishmaniasis in Texas: prevalence and seasonal transmission of Leishmania mexicana in Neotoma micropus.  Am J Trop Med Hyg. 1995;53(1):73-77. doi:10.4269/ajtmh.1995.53.73PubMedGoogle ScholarCrossref
4.
McHugh  CP.  Leishmaniasis in Washington County, Texas.  J Am Acad Dermatol. 2003;49(6):1203. doi:10.1016/S0190-9622(03)02489-7PubMedGoogle ScholarCrossref
5.
Grogl  M, Kreutzer  RD, McHugh  CP, Martin  RK.  Characterization of a Leishmania isolate from the rodent host Neotoma micropus collected in Texas and comparison with human isolates.  Am J Trop Med Hyg. 1991;45(6):714-722. doi:10.4269/ajtmh.1991.45.714PubMedGoogle ScholarCrossref
6.
McHugh  CP, Grogl  M, Kerr  SF.  Isolation of Leishmania mexicana from Neotoma micropus collected in Texas.  J Parasitol. 1990;76(5):741-742. doi:10.2307/3282995PubMedGoogle ScholarCrossref
7.
Kerr  SF, McHugh  CP, Merkelz  R.  Short report: a focus of Leishmania mexicana near Tucson, Arizona.  Am J Trop Med Hyg. 1999;61(3):378-379. doi:10.4269/ajtmh.1999.61.378PubMedGoogle ScholarCrossref
8.
Raymond  RW, McHugh  CP, Witt  LR, Kerr  SF.  Temporal and spatial distribution of Leishmania mexicana infections in a population of Neotoma micropus.  Mem Inst Oswaldo Cruz. 2003;98(2):171-180. doi:10.1590/S0074-02762003000200002PubMedGoogle ScholarCrossref
9.
Petersen  CA.  Leishmaniasis, an emerging disease found in companion animals in the United States.  Top Companion Anim Med. 2009;24(4):182-188. doi:10.1053/j.tcam.2009.06.006PubMedGoogle ScholarCrossref
10.
Trainor  KE, Porter  BF, Logan  KS, Hoffman  RJ, Snowden  KF.  Eight cases of feline cutaneous leishmaniasis in Texas.  Vet Pathol. 2010;47(6):1076-1081. doi:10.1177/0300985810382094PubMedGoogle ScholarCrossref
11.
Alvar  J, Vélez  ID, Bern  C,  et al; WHO Leishmaniasis Control Team.  Leishmaniasis worldwide and global estimates of its incidence.  PLoS One. 2012;7(5):e35671. doi:10.1371/journal.pone.0035671PubMedGoogle ScholarCrossref
12.
Kipp  EJ, Mariscal  J, Armijos  RX, Weigel  M, Waldrup  K.  Genetic evidence of enzootic leishmaniasis in a stray canine and Texas mouse from sites in west and central Texas.  Mem Inst Oswaldo Cruz. 2016;111(10):652-654. doi:10.1590/0074-02760160225PubMedGoogle ScholarCrossref
13.
Bolognia  JLJJ, Schaffer  JV.  Dermatology. 3rd ed. Philadelphia, PA: W.B. Saunders; 2012.
14.
Magill  A.  Leishmania Species: Visceral (Kala-Azar), Cutaneous, and Mucosal. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, PA: Elsevier; 2015:3091-3107.
15.
US Centers for Disease Control and Prevention. Leishmaniasis FAQs. 2013; https://www.cdc.gov/parasites/leishmaniasis/gen_info/faqs.html. Accessed September 20, 2017.
16.
Dockrell  D, Sundar  S, Angus  B, Hobson  R. Infectious disease. In: Walker  B, ed.  Davidson’s Principles and Practice of Medicine. 22nd ed. London, England: Churchill Livingstone; 2014:362-367.
17.
Kumar  V.  Leishmaniasis. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Philadelphia, PA: Elsevier; 2014.
18.
Aronson  N, Herwaldt  BL, Libman  M,  et al.  Diagnosis and treatment of leishmaniasis: clinical practice guidelines by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH).  Clin Infect Dis. 2016;63(12):e202-e264. doi:10.1093/cid/ciw670PubMedGoogle ScholarCrossref
19.
Aronson  N, Herwaldt  BL, Libman  M,  et al.  Diagnosis and treatment of leishmaniasis: clinical practice guidelines by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH).  Am J Trop Med Hyg. 2017;96(1):24-45. doi:10.4269/ajtmh.16-84256PubMedGoogle ScholarCrossref
20.
Habif  TP, Campbell  JL, Chapman  MS, Dinulos  JGH, Zug  KA. Leishmaniasis.  Skin Disease. 3rd ed. Philadelphia, PA: Elsevier; 2011:632-637. doi:10.1016/B978-0-323-07700-2.00024-X
21.
Patterson  J.  Protozoal Infections. Weedon’s Skin Pathology. 4th ed. London, England: Elsevier Ltd; 2016.
22.
Croft  S, Buffet  P. Leishmaniasis. In: Goldman  LSA, ed.  Goldman-Cecil Medicine. 25th ed. Philadelphia, PA: W.B. Saunders; 2015.
23.
Fort  G. Leishmaniasis. In: Ferri  F, ed.  Ferri’s Clinical Advisor. Philadelphia, PA: Elsevier; 2017:712-713.
24.
Melby  P. Leishmaniasis (Leishmania). In: Kliegman  RM, Stanton  BS, Geme  JS,  et al, eds.  Nelson Textbook of Pediatrics. 20th ed. Philadelphia, PA: Elsevier Health Sciences; 2015.
25.
US Centers for Disease Control and Prevention. National Notifiable Diseases Surveillance System (NNDSS): Current and historical disease list. 2017; https://wwwn.cdc.gov/nndss/conditions/. Accessed August 12, 2017.
26.
Maloney  DM, Maloney  JE, Dotson  D, Popov  VL, Sanchez  RL.  Cutaneous leishmaniasis: Texas case diagnosed by electron microscopy.  J Am Acad Dermatol. 2002;47(4):614-616. doi:10.1067/mjd.2002.124606PubMedGoogle ScholarCrossref
27.
Clarke  CF, Bradley  KK, Wright  JH, Glowicz  J.  Case report: Emergence of autochthonous cutaneous leishmaniasis in northeastern Texas and southeastern Oklahoma.  Am J Trop Med Hyg. 2013;88(1):157-161. doi:10.4269/ajtmh.2012.11-0717PubMedGoogle ScholarCrossref
28.
Mead  DG, Cupp  EW.  Occurrence of Lutzomyia anthophora (Diptera: Psychodidae) in Arizona.  J Med Entomol. 1995;32(5):747-748. doi:10.1093/jmedent/32.5.747PubMedGoogle ScholarCrossref
29.
Pavlovsky  EN, Plous  FK, Levine  ND.  Natural nidality of transmissible diseases.  Am J Med Sci. 1966;252(5):161. doi:10.1097/00000441-196611000-00067Google ScholarCrossref
30.
Shaw  J.  The leishmaniases—survival and expansion in a changing world: a mini-review.  Mem Inst Oswaldo Cruz. 2007;102(5):541-547. doi:10.1590/S0074-02762007000500001PubMedGoogle ScholarCrossref
31.
World Health Organization. Leishmaniasis: status of endemicity of cutaneous leishmaniasis. 2015; http://www.who.int/leishmaniasis/burden/en/. Accessed May 24, 2018.
32.
McHugh  CP, Melby  PC, LaFon  SG.  Leishmaniasis in Texas: epidemiology and clinical aspects of human cases.  Am J Trop Med Hyg. 1996;55(5):547-555. doi:10.4269/ajtmh.1996.55.547PubMedGoogle ScholarCrossref
33.
Wright  NA, Davis  LE, Aftergut  KS, Parrish  CA, Cockerell  CJ.  Cutaneous leishmaniasis in Texas: a northern spread of endemic areas.  J Am Acad Dermatol. 2008;58(4):650-652. doi:10.1016/j.jaad.2007.11.008PubMedGoogle ScholarCrossref
34.
Gustafson  TL, Reed  CM, McGreevy  PB, Pappas  MG, Fox  JC, Lawyer  PG.  Human cutaneous leishmaniasis acquired in Texas.  Am J Trop Med Hyg. 1985;34(1):58-63. doi:10.4269/ajtmh.1985.34.58PubMedGoogle ScholarCrossref
35.
McHugh  CP, Thies  ML, Melby  PC,  et al.  Short report: a disseminated infection of Leishmania mexicana in an eastern woodrat, Neotoma floridana, collected in Texas.  Am J Trop Med Hyg. 2003;69(5):470-472.PubMedGoogle ScholarCrossref
36.
Blum  J, Desjeux  P, Schwartz  E, Beck  B, Hatz  C.  Treatment of cutaneous leishmaniasis among travellers.  J Antimicrob Chemother. 2004;53(2):158-166. doi:10.1093/jac/dkh058PubMedGoogle ScholarCrossref
37.
Andrade-Narváez  FJ, Vargas-González  A, Canto-Lara  SB, Damián-Centeno  AG.  Clinical picture of cutaneous leishmaniases due to Leishmania (Leishmania) mexicana in the Yucatan peninsula, Mexico.  Mem Inst Oswaldo Cruz. 2001;96(2):163-167. doi:10.1590/S0074-02762001000200005PubMedGoogle ScholarCrossref
38.
Texas Legislature. Texas Health and Safety Code: Texas Communicable Disease Prevention and Control Act. 1989.
39.
de Vries  HJ, Reedijk  SH, Schallig  HD.  Cutaneous leishmaniasis: recent developments in diagnosis and management.  Am J Clin Dermatol. 2015;16(2):99-109. doi:10.1007/s40257-015-0114-zPubMedGoogle ScholarCrossref
40.
McGwire  BS, Satoskar  AR.  Leishmaniasis: clinical syndromes and treatment.  QJM. 2014;107(1):7-14. doi:10.1093/qjmed/hct116PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Topics
State Requirements