{"paper_id":"024f8dd2-59ca-4dbb-8577-fdd25de4c965","body_text":"A Case of Adnexal Cutaneous Leishmaniasis in Washington DC | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report A Case of Adnexal Cutaneous Leishmaniasis in Washington DC Sinan Akosman, Heeyah Song, Paul Sheils, Tamer Mansour, Keith J Wroblewski, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4441797/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Aug, 2024 Read the published version in Journal of Ophthalmic Inflammation and Infection → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose To report a rare non-endemic case of Leishmania aethiopica in Washington DC. Case report A 68-year-old female presented for a routine examination with a complaint of right upper eyelid lesions for the past 5 months. On examination, a cluster of elevated and erythematous lesions extending from the medial canthus to the brow area of the right eye were seen. Initial treatment with Valtrex based on a suspected viral etiology failed. Although a biopsy was recommended at this time, the patient declined, and subsequent workup included nasolacrimal duct irrigation, blood work to rule out autoimmune etiology, a course of doxycycline, and an MRI, which yielded no improvement. Upon progression of the lesions into persistent plaques on the eyelids, a punch biopsy was performed, confirming leishmaniasis. The patient was then started on a 28-day course of oral miltefosine which led to complete resolution of her symptoms. Conclusion This case underlines the importance of a broad differential including non-endemic diseases, particularly in urban areas with frequent patient travel. Furthermore, the delayed punch biopsy in this case highlights the importance of patient counseling to ensure prompt diagnosis and treatment. cutaneous leishmaniasis parasites punch biopsy non-endemic ocular leishmaniasis Washington DC United States Figures Figure 1 Figure 2 INTRODUCTION Leishmaniasis is an infectious disease caused by the protozoan parasites of the Leishmania genus. Leishmania are transmitted by the bite of infected female phlebotomine sandflies, and known reservoirs of this parasite can be humans as well as animals[ 1 ]. The World Health Organization (WHO) estimates between 700,000 to 1,000,000 new cases of leishmaniasis worldwide annually, with several endemic regions in the Americas, Mediterranean, Europe, and South-East Asia[ 2 ]. The clinical manifestations of leishmaniasis are largely categorized into cutaneous leishmaniasis (CL), mucocutaneous leishmaniasis, or visceral leishmaniasis. CL is the most common form of leishmaniasis and typically presents with skin lesions or ulcers on extremities. Facial lesions are typical in CL, yet eyelid and periorbital involvement is relatively rare, accounting for only about 2% of all CL cases[ 1 , 3 , 4 ]. Diagnosing adnexal leishmaniasis poses a challenge due to its similarity to more common lesions, such as preseptal cellulitis, orbital pseudotumor, sarcoidosis, ophthalmic zoster, allergic reactions, edema due to hypoproteinemia, and thyroid-associated ophthalmopathy[ 4 – 6 ]. In this report, we describe the clinical features, diagnosis, and treatment of a patient with CL presenting with right upper eyelid lesions. CASE REPORT A 68-year-old female presented for a routine examination with a complaint of right upper eyelid lesions for the past 5 months. The patient was of Ethiopian origin and reported recent travel to Ethiopia within the last year. On examination, a cluster of elevated lesions measuring 7 mm x 13 mm near the medial canthus of the right eye were seen extending up to the brow area (Fig. 1 ). The lesions were erythematous with associated soft tissue edema and non-tender to the touch. The lesions were only limited to the right eye. Suspecting a viral or shingles-related cause, a two-week course of Valtrex was prescribed, but it yielded no improvement. In a subsequent evaluation two months later, the lesions worsened with increased erythema, size, and edema, infiltrating deeper in the periocular area. Although biopsy was offered multiple times, the patient repeatedly declined despite multiple counseling attempts. Subsequently the patient was then referred to oculoplastic clinic for further evaluation. Nasolacrimal duct was irrigated to rule out any lacrimal involvement which was negative. Patient was subsequently started on a course of doxycycline and extensive blood work including angiotensin converting enzyme (ACE), immunoglobulin G4 (IgG4), C1 esterase, rheumatoid factor (RF) and antineutrophil cytoplasmic antibodies (ANCA) was done to rule out any autoimmune etiology without much yield. Concerned for possible neoplastic etiology, the MRI face/orbit was completed, which showed soft tissue swelling in the right preseptal and pre-maxillary region extending across the nasion with enhancement of levator palpebrae muscle, right lacrimal gland and nasolacrimal duct. The MRI findings were highly suggestive of inflammatory or infectious etiology. Unfortunately, the lesions persisted. Differentials considered at this juncture included sarcoid/orbital and pseudotumor, with cellulitis being less likely. The patient was then referred to dermatology. During the evaluation, persistent plaques on the right eyelids now involving the bridge of the nose were seen. At this point, patient agreed to a punch biopsy, which showed intracytoplasmic infection most consistent with leishmaniasis. Subsequently, the patient was referred to the National Institutes of Health (NIH). A second biopsy of the right periorbital lesion was done at NIH which was PCR positive for Leishmenia aethiopica . Patient was offered IV amphotericin and a 28-day course of oral miltefosine; our patient elected to proceed with miltefosine, resulting in complete resolution of her lesions without any reported adverse events. Pathology The skin biopsy from the right root of the nose demonstrated a dense pan-dermal infiltrate composed of primarily lymphocytes and histiocytes with scattered other inflammatory cells on low magnification (Fig. 2 , panel A ). On PAS (Fig. 2 , panel B ) and Giemsa (Fig. 2 , panel C ) special staining, within the lymphocytes, vacuoles are identified with small organisms arranged around the periphery of the vacuoles. No gelatinous capsule is identified. These organisms were not visualized on GMS special staining. Taken together, the findings are consistent with an intracellular infection, such as leishmaniasis or histoplasmosis, among others, in the correct clinical context. Correlation with serologic study and deep tissue culture, if indicated, is recommended. The case was discussed with dermatopathology, who agreed with the diagnosis as above. DISCUSSION This case highlights the growing challenge and significance of considering leishmaniasis in physicians' diagnostic considerations in non-endemic regions, including the United States. In the recent years, CL has a rising global prevalence due to increasing migration from endemic areas, which requires healthcare professionals around the world to be able to effectively recognize leishmaniasis and its complications[ 7 ]. In our case, the unusual location of the lesions led to a delay in diagnosis and management. Periorbital lesions in cutaneous leishmaniasis are thought to be rare due to the movement of the eyelids which deters the bite of the fly vector[ 8 , 9 ]. In a study of over 1,700 CL lesions of patients in Turkey, only 1.93% of lesions were located on the eyelid and the periorbital region[ 3 ]. Additionally, adnexal Leishmaniasis commonly presents as a chalazion-like lesion which can often bear resemblance to a multitude of other cutaneous lesions such as those from recurrent chalazion, ulcerative basal cell carcinoma, granulomatous blepharitis, and infected infundibular cysts[ 3 , 10 – 12 ]. The diagnosis of cutaneous leishmaniasis is classically made with a tissue biopsy, which allows for the identification of the microorganisms through staining or culture[ 13 ]. In recent years, PCR has also emerged as a critical tool in diagnosis, offering the option for molecular analysis of specimens, which can be pivotal in guiding treatment strategies[ 14 ]. The effectiveness of these diagnostic methods was particularly significant in this case, as they led to the identification of the causative agent as L. aethiopica. L. aethiopica , one of the most understudied species of Leishmania, is the predominant strain endemic to Ethiopia[ 15 ], where up to 65% of the population in affected areas is reported to have either an active or past infection of leishmaniasis[ 16 ]. The identification of this species was crucial, as L. aethiopica is known for its slower healing time and reduced sensitivity to conventional treatment regimens[ 17 ]. This knowledge underscores the importance of accurate diagnosis and species identification in the effective management of leishmaniasis cases. In selecting treatment regimens for Leishmaniasis, it's crucial to consider the specific Leishmania species, patient toxicity risk, and local medication availability. Historically, pentavalent antimonials were the standard first-line treatment. However, due to rising resistance concerns, the WHO has updated its standard of care to recommend liposomal amphotericin B[ 18 ]. Recently, systemic oral miltefosine has emerged as an alternative treatment. It is often better tolerated than amphotericin B, which is associated with renal insufficiency and other serious side effects. Initially developed for cancer therapy, miltefosine has since received Food and Drug Administration (FDA) approval for treating three specific species of New World leishmaniasis and has been shown to be effective against L. aethiopica in several small clinical trials[ 19 – 21 ]. In this case, our patient's successful treatment involved a 28-day course of miltefosine. Lastly, this case highlights the diagnostic value of a prompt skin biopsy, which would have undoubtedly led to a sooner diagnosis and treatment for the patient, as well as avoided unnecessary laboratory tests, diagnostic images, and healthcare expenses. Patient education and clear communication of risks and benefits of such procedures must be effectively achieved in order to achieve optimal outcome for all parties. Abbreviations World Health Organization (WHO); cutaneous leishmaniasis (CL); angiotensin converting enzyme (ACE); Immunoglobulin G4 (IgG4); rheumatoid (RH); antineutrophil cytoplasmic antibodies (ANCA); National Institutes of Health (NIH); Food and Drug Administration (FDA); periodic acid-Schiff (PAS); grocott’s methenamine silver (GMS) Declarations Ethics approval and consent to participate Not applicable Consent for publication Patient provided oral and written consent for this case to be published. Availability of data and material Data sharing is not applicable as no datasets were generated for this study. Competing interests The authors declare that they have no competing interests Funding Not applicable Authors' contributions HS, TM, and LR cared for the patient. SA and HS conceptualized and lead the writing, revision, and editing of the manuscript. TM, LR, PS, and KJW assisted with the writing of the manuscript. All authors read, reviewed, and approved the final manuscript. Acknowledgements Not applicable References Pahuja S, Puranik C, Jelliti B, Khairallah M, Sangwan VS (2013) Parasitic Infections of the External Eye. Ocul Immunol Inflamm 21:292–299. https://doi.org/10.3109/09273948.2013.770889 (2023) Leishmaniasis. World Health Organization Satici A, Gurler B, Aslan G, Ozturk I (2003) Ocular involvement in cutaneous leishmaniasis four cases with blepharoconjunctivitis. Eur J Epidemiol 19:263–266. https://doi.org/10.1023/B:EJEP.0000020346.15800.d3 Mignot G, Bhattacharya Y, Reddy A (2021) Ocular Leishmaniasis - A systematic review. Indian J Ophthalmol 69:1052. https://doi.org/10.4103/ijo.IJO_2232_20 Cohen JI (2013) Herpes Zoster. N Engl J Med 369:255–263. https://doi.org/10.1056/NEJMcp1302674 Hauser A, Fogarasi S (2010) Periorbital and Orbital Cellulitis. Pediatr Rev 31:242–249. https://doi.org/10.1542/pir.31.6.242 Curtin JM, Aronson NE (2021) Leishmaniasis in the United States: Emerging Issues in a Region of Low Endemicity. Microorganisms 9:578. https://doi.org/10.3390/microorganisms9030578 Jafari AK, Akhyani M, Valikhani M, Ghodsi ZS, Barikbin B, Toosi S (2006) Bilateral cutaneous leishmaniasis of upper eyelids: a case report. Dermatol Online J 12:20 Mencía-Gutiérrez E, Gutiérrez-Díaz E, Rodríguez-Peralto JL, Monsalve-Córdova J (2005) Old World eyelid cutaneous leishmaniasis: a case report. Dermatol Online J 11:29 Sadeghian G, Nilfroushzadeh MA, Moradi SH, Hanjani SH (2005) Ocular leishmaniasis: a case report. Dermatol Online J 11:19 Yaghoobi R, Maraghi S, Bagherani N, Rafiei A (2010) Cutaneous Leishmaniasis of the Lid: A Report of Nine Cases. Korean J Ophthalmol 24:40. https://doi.org/10.3341/kjo.2010.24.1.40 Veraldi S, Bottini S, Currò N, Gianotti R (2010) Leishmaniasis of the eyelid mimicking an infundibular cyst and review of the literature on ocular leishmaniasis. Int J Infect Dis 14:e230–e232. https://doi.org/10.1016/j.ijid.2009.07.024 Aronson N, Herwaldt BL, Libman M, Pearson R, Lopez-Velez R, Weina P, Carvalho E, Ephros M, Jeronimo S, Magill A (2017) 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 96:24–45. https://doi.org/10.4269/ajtmh.16-84256 Aronson N, Herwaldt BL, Libman M, Pearson R, Lopez-Velez R, Weina P, Carvalho EM, Ephros M, Jeronimo S, Magill A (2016) 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 63:e202–e264. https://doi.org/10.1093/cid/ciw670 Mengeot L, Yombi J-C, Baeck M (2022) Cutaneous leishmaniasis due to Leishmania aethiopica: A therapeutic challenge. JAAD Case Rep 20:72–75. https://doi.org/10.1016/j.jdcr.2021.12.028 Bugssa G (2014) The Current Status of Cutaneous Leishmaniasis and the Pattern of Lesions in Ochollo Primary School Students, Ochollo, Southwestern Ethiopia. Sci J Clin Med 3:111. https://doi.org/10.11648/j.sjcm.20140306.13 van Henten S, Adriaensen W, Fikre H, Akuffo H, Diro E, Hailu A, Van der Auwera G, van Griensven J (2018) Cutaneous Leishmaniasis Due to Leishmania aethiopica. EClinicalMedicine 6:69–81. https://doi.org/10.1016/j.eclinm.2018.12.009 Alvar J, WHO (2005) Report of a WHO informal consultation on liposomal amphotericin B in the treatment of visceral leishmaniasis. World Health Organization, Rome, Italy Ware JM, O’Connell EM, Brown T, Wetzler L, Talaat KR, Nutman TB, Nash TE (2021) Efficacy and Tolerability of Miltefosine in the Treatment of Cutaneous Leishmaniasis. Clin Infect Dis 73:e2457–e2562. https://doi.org/10.1093/cid/ciaa1238 Alemu AY, Derseh L, Kaba M, Gadisa E, Alemu K (2023) Treatment outcomes of cutaneous leishmaniasis due to Leishmania aethiopica: A systematic review and meta-analysis. PLoS ONE 18:e0293529. https://doi.org/10.1371/journal.pone.0293529 Van Griensven J, Gadisa E, Aseffa A, Hailu A, Beshah AM, Diro E (2016) Treatment of Cutaneous Leishmaniasis Caused by Leishmania aethiopica: A Systematic Review. PLoS Negl Trop Dis 10:e0004495. https://doi.org/10.1371/journal.pntd.0004495 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 23 Aug, 2024 Read the published version in Journal of Ophthalmic Inflammation and Infection → Version 1 posted Editorial decision: Accepted 08 Aug, 2024 Reviews received at journal 12 Jun, 2024 Reviewers agreed at journal 06 Jun, 2024 Reviewers invited by journal 06 Jun, 2024 Submission checks completed at journal 27 May, 2024 Editor assigned by journal 27 May, 2024 First submitted to journal 18 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-4441797\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Short Report\",\"associatedPublications\":[],\"authors\":[{\"id\":311335441,\"identity\":\"935119c5-0dfd-43db-abb2-1e676a898126\",\"order_by\":0,\"name\":\"Sinan Akosman\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAv0lEQVRIiWNgGAWjYFACNgjFD6GYSdAi2UCyFoMDxGqRbz+W+PBnjl2e8fk1ZhIMFdaJDYS0GJxJO2zMuy252OzGG6CWM+lEaGFIb5Nm3MacuO3G2W0SjG2HCWuR73/eJvlzW33i5hkgLf+I0MJwI+2YBO+2w4kb+HuBWhqI0GJw41ky0C/HE2fc4P9skXAs3ZgIh6UZPvy5rTqxv/9Y4o0PNdayhB0GBxIJDAwJxCsHAf4DpKkfBaNgFIyCkQMAySlBl+Npw9MAAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"Department of Ophthalmology, George Washington University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Sinan\",\"middleName\":\"\",\"lastName\":\"Akosman\",\"suffix\":\"\"},{\"id\":311335442,\"identity\":\"fa4a5ea3-8bb8-412b-b1e9-84fb49b1e184\",\"order_by\":1,\"name\":\"Heeyah Song\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Department of Ophthalmology, George Washington University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Heeyah\",\"middleName\":\"\",\"lastName\":\"Song\",\"suffix\":\"\"},{\"id\":311335443,\"identity\":\"356025ce-9d53-4a4b-ac2b-e53433482176\",\"order_by\":2,\"name\":\"Paul Sheils\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Department of Ophthalmology, George Washington University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Paul\",\"middleName\":\"\",\"lastName\":\"Sheils\",\"suffix\":\"\"},{\"id\":311335444,\"identity\":\"9c482d56-1ae6-4716-a39a-448cdf1319ee\",\"order_by\":3,\"name\":\"Tamer Mansour\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Department of Ophthalmology, George Washington University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Tamer\",\"middleName\":\"\",\"lastName\":\"Mansour\",\"suffix\":\"\"},{\"id\":311335445,\"identity\":\"04ee4be4-f310-4e93-b60a-4742019cdea9\",\"order_by\":4,\"name\":\"Keith J Wroblewski\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Department of Ophthalmology, George Washington University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Keith\",\"middleName\":\"J\",\"lastName\":\"Wroblewski\",\"suffix\":\"\"},{\"id\":311335446,\"identity\":\"d60aab85-68a6-4e08-946c-7cabb4d481e2\",\"order_by\":5,\"name\":\"Lamise Rajjoub\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Department of Ophthalmology, George Washington University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Lamise\",\"middleName\":\"\",\"lastName\":\"Rajjoub\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2024-05-18 16:25:23\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-4441797/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-4441797/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1186/s12348-024-00423-z\",\"type\":\"published\",\"date\":\"2024-08-23T15:57:30+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":58169336,\"identity\":\"ec421d24-fb3d-434e-8eca-3f1043fb8b0c\",\"added_by\":\"auto\",\"created_at\":\"2024-06-12 03:30:38\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":3665945,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eShows an external photograph of her right eye which demonstrates erythematous, infiltrative plaques that extend across the medial canthal region up toward the brow.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure128.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4441797/v1/34748b3a811956177b382b9e.png\"},{\"id\":58169335,\"identity\":\"2391e44f-59f0-468f-86fa-6bccc7064a02\",\"added_by\":\"auto\",\"created_at\":\"2024-06-12 03:30:38\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":4896971,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eHistopathologic features consistent with intracellular infection. A: Dense pan-dermal infiltrate (hematoxylin-eosin staining, original magnification × 4); B: Parasitized histiocytes with staining of Leishmania amastigotes (PAS, original magnification × 40); and C: Parasitized histiocytes with staining of Leishmania amastigotes (Giemsa, original magnification × 40).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure224.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4441797/v1/66a5d81fb91d596349ac3c10.png\"},{\"id\":63300631,\"identity\":\"f5e4fb34-a264-4a93-8934-481b02960e2e\",\"added_by\":\"auto\",\"created_at\":\"2024-08-26 16:15:56\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":9094027,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4441797/v1/c0aef874-1bca-49d3-9d7d-42921a033bcd.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\" A Case of Adnexal Cutaneous Leishmaniasis in Washington DC\",\"fulltext\":[{\"header\":\"INTRODUCTION\",\"content\":\"\\u003cp\\u003eLeishmaniasis is an infectious disease caused by the protozoan parasites of the \\u003cem\\u003eLeishmania\\u003c/em\\u003e genus. \\u003cem\\u003eLeishmania\\u003c/em\\u003e are transmitted by the bite of infected female phlebotomine sandflies, and known reservoirs of this parasite can be humans as well as animals[\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. The World Health Organization (WHO) estimates between 700,000 to 1,000,000 new cases of leishmaniasis worldwide annually, with several endemic regions in the Americas, Mediterranean, Europe, and South-East Asia[\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThe clinical manifestations of leishmaniasis are largely categorized into cutaneous leishmaniasis (CL), mucocutaneous leishmaniasis, or visceral leishmaniasis. CL is the most common form of leishmaniasis and typically presents with skin lesions or ulcers on extremities. Facial lesions are typical in CL, yet eyelid and periorbital involvement is relatively rare, accounting for only about 2% of all CL cases[\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eDiagnosing adnexal leishmaniasis poses a challenge due to its similarity to more common lesions, such as preseptal cellulitis, orbital pseudotumor, sarcoidosis, ophthalmic zoster, allergic reactions, edema due to hypoproteinemia, and thyroid-associated ophthalmopathy[\\u003cspan additionalcitationids=\\\"CR5\\\" citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. In this report, we describe the clinical features, diagnosis, and treatment of a patient with CL presenting with right upper eyelid lesions.\\u003c/p\\u003e\"},{\"header\":\"CASE REPORT\",\"content\":\"\\u003cp\\u003eA 68-year-old female presented for a routine examination with a complaint of right upper eyelid lesions for the past 5 months. The patient was of Ethiopian origin and reported recent travel to Ethiopia within the last year. On examination, a cluster of elevated lesions measuring 7 mm x 13 mm near the medial canthus of the right eye were seen extending up to the brow area (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). The lesions were erythematous with associated soft tissue edema and non-tender to the touch. The lesions were only limited to the right eye. Suspecting a viral or shingles-related cause, a two-week course of Valtrex was prescribed, but it yielded no improvement. In a subsequent evaluation two months later, the lesions worsened with increased erythema, size, and edema, infiltrating deeper in the periocular area. Although biopsy was offered multiple times, the patient repeatedly declined despite multiple counseling attempts. Subsequently the patient was then referred to oculoplastic clinic for further evaluation. Nasolacrimal duct was irrigated to rule out any lacrimal involvement which was negative. Patient was subsequently started on a course of doxycycline and extensive blood work including angiotensin converting enzyme (ACE), immunoglobulin G4 (IgG4), C1 esterase, rheumatoid factor (RF) and antineutrophil cytoplasmic antibodies (ANCA) was done to rule out any autoimmune etiology without much yield. Concerned for possible neoplastic etiology, the MRI face/orbit was completed, which showed soft tissue swelling in the right preseptal and pre-maxillary region extending across the nasion with enhancement of levator palpebrae muscle, right lacrimal gland and nasolacrimal duct. The MRI findings were highly suggestive of inflammatory or infectious etiology. Unfortunately, the lesions persisted. Differentials considered at this juncture included sarcoid/orbital and pseudotumor, with cellulitis being less likely.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe patient was then referred to dermatology. During the evaluation, persistent plaques on the right eyelids now involving the bridge of the nose were seen. At this point, patient agreed to a punch biopsy, which showed intracytoplasmic infection most consistent with leishmaniasis. Subsequently, the patient was referred to the National Institutes of Health (NIH). A second biopsy of the right periorbital lesion was done at NIH which was PCR positive for \\u003cem\\u003eLeishmenia aethiopica\\u003c/em\\u003e. Patient was offered IV amphotericin and a 28-day course of oral miltefosine; our patient elected to proceed with miltefosine, resulting in complete resolution of her lesions without any reported adverse events.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePathology\\u003c/h2\\u003e \\u003cp\\u003eThe skin biopsy from the right root of the nose demonstrated a dense pan-dermal infiltrate composed of primarily lymphocytes and histiocytes with scattered other inflammatory cells on low magnification (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cb\\u003epanel A\\u003c/b\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eOn PAS (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cb\\u003epanel B\\u003c/b\\u003e) and Giemsa (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cb\\u003epanel C\\u003c/b\\u003e) special staining, within the lymphocytes, vacuoles are identified with small organisms arranged around the periphery of the vacuoles. No gelatinous capsule is identified. These organisms were not visualized on GMS special staining.\\u003c/p\\u003e \\u003cp\\u003eTaken together, the findings are consistent with an intracellular infection, such as leishmaniasis or histoplasmosis, among others, in the correct clinical context. Correlation with serologic study and deep tissue culture, if indicated, is recommended. The case was discussed with dermatopathology, who agreed with the diagnosis as above.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"DISCUSSION\",\"content\":\"\\u003cp\\u003eThis case highlights the growing challenge and significance of considering leishmaniasis in physicians' diagnostic considerations in non-endemic regions, including the United States. In the recent years, CL has a rising global prevalence due to increasing migration from endemic areas, which requires healthcare professionals around the world to be able to effectively recognize leishmaniasis and its complications[\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIn our case, the unusual location of the lesions led to a delay in diagnosis and management. Periorbital lesions in cutaneous leishmaniasis are thought to be rare due to the movement of the eyelids which deters the bite of the fly vector[\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. In a study of over 1,700 CL lesions of patients in Turkey, only 1.93% of lesions were located on the eyelid and the periorbital region[\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. Additionally, adnexal Leishmaniasis commonly presents as a chalazion-like lesion which can often bear resemblance to a multitude of other cutaneous lesions such as those from recurrent chalazion, ulcerative basal cell carcinoma, granulomatous blepharitis, and infected infundibular cysts[\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR11\\\" citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThe diagnosis of cutaneous leishmaniasis is classically made with a tissue biopsy, which allows for the identification of the microorganisms through staining or culture[\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. In recent years, PCR has also emerged as a critical tool in diagnosis, offering the option for molecular analysis of specimens, which can be pivotal in guiding treatment strategies[\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]. The effectiveness of these diagnostic methods was particularly significant in this case, as they led to the identification of the causative agent as \\u003cem\\u003eL. aethiopica.\\u003c/em\\u003e\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003eL. aethiopica\\u003c/em\\u003e, one of the most understudied species of Leishmania, is the predominant strain endemic to Ethiopia[\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e], where up to 65% of the population in affected areas is reported to have either an active or past infection of leishmaniasis[\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e]. The identification of this species was crucial, as \\u003cem\\u003eL. aethiopica\\u003c/em\\u003e is known for its slower healing time and reduced sensitivity to conventional treatment regimens[\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e]. This knowledge underscores the importance of accurate diagnosis and species identification in the effective management of leishmaniasis cases.\\u003c/p\\u003e \\u003cp\\u003eIn selecting treatment regimens for Leishmaniasis, it's crucial to consider the specific Leishmania species, patient toxicity risk, and local medication availability. Historically, pentavalent antimonials were the standard first-line treatment. However, due to rising resistance concerns, the WHO has updated its standard of care to recommend liposomal amphotericin B[\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]. Recently, systemic oral miltefosine has emerged as an alternative treatment. It is often better tolerated than amphotericin B, which is associated with renal insufficiency and other serious side effects. Initially developed for cancer therapy, miltefosine has since received Food and Drug Administration (FDA) approval for treating three specific species of New World leishmaniasis and has been shown to be effective against L. aethiopica in several small clinical trials[\\u003cspan additionalcitationids=\\\"CR20\\\" citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e]. In this case, our patient's successful treatment involved a 28-day course of miltefosine.\\u003c/p\\u003e \\u003cp\\u003eLastly, this case highlights the diagnostic value of a prompt skin biopsy, which would have undoubtedly led to a sooner diagnosis and treatment for the patient, as well as avoided unnecessary laboratory tests, diagnostic images, and healthcare expenses. Patient education and clear communication of risks and benefits of such procedures must be effectively achieved in order to achieve optimal outcome for all parties.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003eWorld Health Organization (WHO); cutaneous leishmaniasis (CL); angiotensin converting enzyme (ACE); Immunoglobulin G4 (IgG4); rheumatoid (RH); antineutrophil cytoplasmic antibodies (ANCA); National Institutes of Health (NIH); Food and Drug Administration (FDA); periodic acid-Schiff (PAS); grocott’s methenamine silver (GMS)\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003ePatient provided oral and written consent for this case to be published.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and material\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eData sharing is not applicable as no datasets were generated for this study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no competing interests\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026apos; contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eHS, TM, and LR cared for the patient. SA and HS conceptualized and lead the writing, revision, and editing of the manuscript. TM, LR, PS, and KJW assisted with the writing of the manuscript. All authors read, reviewed, and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003ePahuja S, Puranik C, Jelliti B, Khairallah M, Sangwan VS (2013) Parasitic Infections of the External Eye. 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Microorganisms 9:578. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.3390/microorganisms9030578\\u003c/span\\u003e\\u003cspan address=\\\"10.3390/microorganisms9030578\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJafari AK, Akhyani M, Valikhani M, Ghodsi ZS, Barikbin B, Toosi S (2006) Bilateral cutaneous leishmaniasis of upper eyelids: a case report. Dermatol Online J 12:20\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMenc\\u0026iacute;a-Guti\\u0026eacute;rrez E, Guti\\u0026eacute;rrez-D\\u0026iacute;az E, Rodr\\u0026iacute;guez-Peralto JL, Monsalve-C\\u0026oacute;rdova J (2005) Old World eyelid cutaneous leishmaniasis: a case report. Dermatol Online J 11:29\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSadeghian G, Nilfroushzadeh MA, Moradi SH, Hanjani SH (2005) Ocular leishmaniasis: a case report. Dermatol Online J 11:19\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eYaghoobi R, Maraghi S, Bagherani N, Rafiei A (2010) Cutaneous Leishmaniasis of the Lid: A Report of Nine Cases. Korean J Ophthalmol 24:40. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.3341/kjo.2010.24.1.40\\u003c/span\\u003e\\u003cspan address=\\\"10.3341/kjo.2010.24.1.40\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eVeraldi S, Bottini S, Curr\\u0026ograve; N, Gianotti R (2010) Leishmaniasis of the eyelid mimicking an infundibular cyst and review of the literature on ocular leishmaniasis. Int J Infect Dis 14:e230\\u0026ndash;e232. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.ijid.2009.07.024\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.ijid.2009.07.024\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAronson N, Herwaldt BL, Libman M, Pearson R, Lopez-Velez R, Weina P, Carvalho E, Ephros M, Jeronimo S, Magill A (2017) 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 96:24\\u0026ndash;45. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.4269/ajtmh.16-84256\\u003c/span\\u003e\\u003cspan address=\\\"10.4269/ajtmh.16-84256\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAronson N, Herwaldt BL, Libman M, Pearson R, Lopez-Velez R, Weina P, Carvalho EM, Ephros M, Jeronimo S, Magill A (2016) 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 63:e202\\u0026ndash;e264. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1093/cid/ciw670\\u003c/span\\u003e\\u003cspan address=\\\"10.1093/cid/ciw670\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMengeot L, Yombi J-C, Baeck M (2022) Cutaneous leishmaniasis due to Leishmania aethiopica: A therapeutic challenge. JAAD Case Rep 20:72\\u0026ndash;75. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.jdcr.2021.12.028\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.jdcr.2021.12.028\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBugssa G (2014) The Current Status of Cutaneous Leishmaniasis and the Pattern of Lesions in Ochollo Primary School Students, Ochollo, Southwestern Ethiopia. Sci J Clin Med 3:111. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.11648/j.sjcm.20140306.13\\u003c/span\\u003e\\u003cspan address=\\\"10.11648/j.sjcm.20140306.13\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003evan Henten S, Adriaensen W, Fikre H, Akuffo H, Diro E, Hailu A, Van der Auwera G, van Griensven J (2018) Cutaneous Leishmaniasis Due to Leishmania aethiopica. EClinicalMedicine 6:69\\u0026ndash;81. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.eclinm.2018.12.009\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.eclinm.2018.12.009\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAlvar J, WHO (2005) Report of a WHO informal consultation on liposomal amphotericin B in the treatment of visceral leishmaniasis. World Health Organization, Rome, Italy\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWare JM, O\\u0026rsquo;Connell EM, Brown T, Wetzler L, Talaat KR, Nutman TB, Nash TE (2021) Efficacy and Tolerability of Miltefosine in the Treatment of Cutaneous Leishmaniasis. Clin Infect Dis 73:e2457\\u0026ndash;e2562. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1093/cid/ciaa1238\\u003c/span\\u003e\\u003cspan address=\\\"10.1093/cid/ciaa1238\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAlemu AY, Derseh L, Kaba M, Gadisa E, Alemu K (2023) Treatment outcomes of cutaneous leishmaniasis due to Leishmania aethiopica: A systematic review and meta-analysis. PLoS ONE 18:e0293529. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1371/journal.pone.0293529\\u003c/span\\u003e\\u003cspan address=\\\"10.1371/journal.pone.0293529\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eVan Griensven J, Gadisa E, Aseffa A, Hailu A, Beshah AM, Diro E (2016) Treatment of Cutaneous Leishmaniasis Caused by Leishmania aethiopica: A Systematic Review. PLoS Negl Trop Dis 10:e0004495. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1371/journal.pntd.0004495\\u003c/span\\u003e\\u003cspan address=\\\"10.1371/journal.pntd.0004495\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"journal-of-ophthalmic-inflammation-and-infection\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"joii\",\"sideBox\":\"Learn more about [Journal of Ophthalmic Inflammation and Infection](http://joii-journal.springeropen.com)\",\"snPcode\":\"12348\",\"submissionUrl\":\"https://submission.nature.com/new-submission/12348/3\",\"title\":\"Journal of Ophthalmic Inflammation and Infection\",\"twitterHandle\":\"@SpringerOpen\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC/SO AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"cutaneous leishmaniasis, parasites, punch biopsy, non-endemic, ocular leishmaniasis, Washington DC, United States\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-4441797/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-4441797/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003ePurpose\\u003c/h2\\u003e \\u003cp\\u003eTo report a rare non-endemic case of \\u003cem\\u003eLeishmania aethiopica\\u003c/em\\u003e in Washington DC.\\u003c/p\\u003e\\u003ch2\\u003eCase report\\u003c/h2\\u003e \\u003cp\\u003eA 68-year-old female presented for a routine examination with a complaint of right upper eyelid lesions for the past 5 months. On examination, a cluster of elevated and erythematous lesions extending from the medial canthus to the brow area of the right eye were seen. Initial treatment with Valtrex based on a suspected viral etiology failed. Although a biopsy was recommended at this time, the patient declined, and subsequent workup included nasolacrimal duct irrigation, blood work to rule out autoimmune etiology, a course of doxycycline, and an MRI, which yielded no improvement. Upon progression of the lesions into persistent plaques on the eyelids, a punch biopsy was performed, confirming leishmaniasis. The patient was then started on a 28-day course of oral miltefosine which led to complete resolution of her symptoms.\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003eThis case underlines the importance of a broad differential including non-endemic diseases, particularly in urban areas with frequent patient travel. Furthermore, the delayed punch biopsy in this case highlights the importance of patient counseling to ensure prompt diagnosis and treatment.\\u003c/p\\u003e\",\"manuscriptTitle\":\" A Case of Adnexal Cutaneous Leishmaniasis in Washington DC\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-06-12 03:30:33\",\"doi\":\"10.21203/rs.3.rs-4441797/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Accepted\",\"date\":\"2024-08-08T20:43:16+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2024-06-12T11:40:09+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"303639066734615701275051353106990500038\",\"date\":\"2024-06-06T11:50:04+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2024-06-06T10:42:01+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2024-05-27T09:25:27+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2024-05-27T09:25:27+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Journal of Ophthalmic Inflammation and Infection\",\"date\":\"2024-05-18T16:24:04+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"journal-of-ophthalmic-inflammation-and-infection\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"joii\",\"sideBox\":\"Learn more about [Journal of Ophthalmic Inflammation and Infection](http://joii-journal.springeropen.com)\",\"snPcode\":\"12348\",\"submissionUrl\":\"https://submission.nature.com/new-submission/12348/3\",\"title\":\"Journal of Ophthalmic Inflammation and Infection\",\"twitterHandle\":\"@SpringerOpen\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC/SO AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"89e081b9-d29d-42d7-8ee2-443f5e3e67ee\",\"owner\":[],\"postedDate\":\"June 12th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2024-08-26T16:08:43+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-4441797\",\"link\":\"https://doi.org/10.1186/s12348-024-00423-z\",\"journal\":{\"identity\":\"journal-of-ophthalmic-inflammation-and-infection\",\"isVorOnly\":false,\"title\":\"Journal of Ophthalmic Inflammation and Infection\"},\"publishedOn\":\"2024-08-23 15:57:30\",\"publishedOnDateReadable\":\"August 23rd, 2024\"},\"versionCreatedAt\":\"2024-06-12 03:30:33\",\"video\":\"\",\"vorDoi\":\"10.1186/s12348-024-00423-z\",\"vorDoiUrl\":\"https://doi.org/10.1186/s12348-024-00423-z\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-4441797\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-4441797\",\"identity\":\"rs-4441797\",\"version\":[\"v1\"]},\"buildId\":\"qtupq5eGEP_6zYnWcrvyt\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}