What are the guideline sources, guidelines and references for Cutaneous and mucocutaneous leishmaniasis ?
Guideline sources The following summarized guidelines for the evaluation and management of cutaneous and mucocutaneous leishmaniasis are prepared by our editorial team based on guidelines from the Infectious Diseases Society of America (IDSA/ASTMH 2017). 1 Guidelines 1. Diagnostic investigations Clinical examination: assess for mucosal symptoms snd signs, even during initial evaluation, in all patients with cutaneous leishmaniasis at risk for mucocutaneous leishmaniasis on the basis of the etiologic agent of Leishmania infection, if known, and the region in the New World in which infection was acquired. B Show 3 more Laboratory testing (general principles): Attempt multiple diagnostic approaches to maximize the likelihood of a positive Leishmania result, using methods such as: visualization of the characteristic amastigote in smears or tissue (histopathology) parasite isolation by culture molecular detection of parasite DNA. B https://web.pathway.md/diseases/recVQKiNkLRDIHqBS 1/4 6/23/23, 3:36 AM Cutaneous and mucocutaneous leishmaniasis Pathway Show 2 more Laboratory testing (deoxyribonucleic acid-based assays): Obtain DNA-based assays, especially if other diagnostic testing is unrevealing. Recognize that they are emerging as the most sensitive assays for the diagnosis of leishmaniasis. B Obtain molecular amplification assays because they are the most sensitive Leishmania tests currently available. B Laboratory testing (serology): do not obtain serologic testing as part of the diagnostic evaluation for cutaneous leishmaniasis. Recognize that the currently available serologic assays are neither sensitive nor specific for the diagnosis of cutaneous leishmaniasis. D Skin testing: do not obtain Leishmania skin testing for any form of leishmaniasis. Recognize that there are no standardized, approved, or commercially available skin-test products in North America. D 2. Diagnostic procedures Biopsy: collect tissue specimens from lesions when cutaneous leishmaniasis is clinically suspected. Recognize that full-thickness skin biopsy specimens allow for simultaneous testing for other diagnoses, such as by histopathology and cultures. B Show 2 more 3. Medical management General principles: consider offering empiric treatment based on individualized risk-benefit assessment after a careful diagnostic evaluation in which neither leishmaniasis nor another diagnosis is confirmed. C Show 4 more Systemic therapy (indications): administer systemic anti-leishmanial therapy in all patients with clinically manifest, metastatic, American mucocutaneous leishmaniasis, with the goals of preventing morbidity (such as disfigurement) and mortality (such as from aspiration pneumonia or respiratory obstruction). B Show 4 more Systemic therapy (choice of agent, dose and duration): individualize the choice of agent, dose, and duration of therapy in patients with cutaneous/mucocutaneous leishmaniasis to maximize effectiveness and to minimize toxicity. B Show 3 more Local therapy: Prefer local therapy for the treatment of clinically simple Old World cutaneous leishmaniasis lesions. Consider using local therapy for localized New World cutaneous leishmaniasis caused by Leishmania species not associated with increased risk for mucocutaneous leishmaniasis. B https://web.pathway.md/diseases/recVQKiNkLRDIHqBS 2/4 6/23/23, 3:36 AM Cutaneous and mucocutaneous leishmaniasis Pathway Perform debridement of eschars overlying ulcers before administering local therapy in patients with cutaneous leishmaniasis and treat any secondary infection to maximize treatment effect. B Corticosteroids: administer prophylactic corticosteroid therapy in patients with mucocutaneous leishmaniasis with laryngeal/pharyngeal involvement and increased risk for respiratory obstruction, as indicated by symptoms and otolaryngologic/radiologic examinations, because of the potential for inflammatory reactions after initiation of anti-leishmanial therapy. B 4. Specific circumstances Patients with human immunodeficiency virus/acquired immunodeficiency syndrome: offer systemic anti-leishmanial therapy in patients with human immunodeficiency virus/AIDS-associated cutaneous/mucocutaneous leishmaniasis, particularly in moderately to severely immunosuppressed patients (such as having CD4+ T-lymphocyte counts < 200-350 cells/mm ), possibly being at increased risk for suboptimal therapeutic responses, for post-treatment relapses, and for cutaneous, mucosal, or visceral dissemination. B Show 2 more Patients with other causes of immunosuppression: Do not obtain routine serologic screening of organ donors from leishmaniasis-endemic areas. Obtain clinical and laboratory monitoring of the organ recipient in the post-transplant period if an available donor is known to be seropositive, rather than to reject the organ for transplant. D Consider offering systemic therapy and standard drug regimens for the pertinent setting/species (such as geographic area where the infection was acquired) in patients with cutaneous/mucocutaneous leishmaniasis associated with the use of TNF- antagonist therapy. C 5. Patient education Patient education: Educate and provide patients with cutaneous leishmaniasis at risk for mucocutaneous leishmaniasis with personalized documentation about the importance of seeking medical attention for possible mucocutaneous leishmaniasis if they ever develop persistent, atypical (unusual for the patient) naso-oropharyngeal/laryngeal manifestations not having a clear etiology. B Educate patients with cutaneous leishmaniasis about the signs and symptoms of relapse and mucocutaneous leishmaniasis and instruct them to seek medical attention anytime these appear. B 6. Follow-up and surveillance Observation: offer clinical observation alone for spontaneously healing skin lesions in immunocompetent patients with cutaneous leishmaniasis caused by infection with Leishmania https://web.pathway.md/diseases/recVQKiNkLRDIHqBS 3/4 6/23/23, 3:36 AM Cutaneous and mucocutaneous leishmaniasis Pathway species not associated with increased risk for mucocutaneous leishmaniasis, if the patient concurs with this management. B Show 2 more Indications for referral: refer for consultation with a leishmaniasis expert about other treatment options for the management of patients with cutaneous leishmaniasis with lesions associated with therapeutic failure. B Show 2 more Monitoring of treatment response: assess patients with cutaneous leishmaniasis for treatment response by clinical criteria. Do not obtain repeated parasitologic testing if the skin lesion appears to be healing. B Show 3 more Monitoring for progression: Obtain active clinical monitoring in patients with cutaneous leishmaniasis, including by performing a careful nasal and oropharyngeal examination periodically up to 1 year, or at least 2 years if at increased risk for mucocutaneous leishmaniasis. Educate patients with cutaneous leishmaniasis about the signs and symptoms of relapse and mucocutaneous leishmaniasis and instruct them to seek medical attention anytime these appear. B Evaluate patients with cutaneous leishmaniasis for mucocutaneous leishmaniasis, including performing fiberoptic examination of the affected area if relevant, if symptoms such as chronic nasal stuffiness, epistaxis, or hoarseness or findings such as septal perforation occur anytime in patients with a prior or current diagnosis of cutaneous leishmaniasis or a scar consistent with prior cutaneous leishmaniasis. B Management of treatment failure: offer additional therapy (but not necessarily always a different agent or approach) in patients with cutaneous leishmaniasis if new skin lesions develop or existing lesions worsen. Offer additional therapy if there is incomplete healing by 3 months after completion of the treatment course. B References 1. Naomi Aronson, Barbara L Herwaldt, Michael Libman 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 Jan 11; 96 1 24 45. Open https://web.pathway.md/diseases/recVQKiNkLRDIHqBS 4/4