Andreas Lindner, MD, Gabriela Equihua Martinez, MScPH, and Cristina Moreno Del Castillo, MScIH of the BER site have recently identified three patients who acquired cutaneous leishmaniasis in Mexico. Since this is a popular tourist destination, we want you to be aware of this risk and to be on the watch for patients returning from Mexico with this disease. Full details below.
Imported American Cutaneous Leishmaniasis – Germany ex Mexico
From April to August 2023, the Institute of International Health at Charité University Medicine in Berlin, Germany, a member of the GeoSentinel network, diagnosed three unrelated cases of imported cutaneous leishmaniasis (CL) in patients exposed in southeastern Mexico.
Patient 1. A 31-year-old female originally from Russia currently residing in Tulum, Quintana Roo, Mexico, presented to our clinic with a 2 cm ulcerative skin lesion on her knee of 15 weeks duration that had been previously confirmed as leishmaniasis in Mexico through microscopy. A PCR analysis of a lesion biopsy at our Institute confirmed Leishmania (L.) mexicana as the causative agent. Initially, she underwent systemic ketoconazole therapy; however, a reevaluation after three months indicated treatment failure. Subsequently, she received additional treatment with perilesional antimonials in Mexico, which successfully led to the lesion’s healing.
Patient 2. A 23-year-old male originally from Bacalar, Quintana Roo, Mexico who was travelling through Europe, presented with a 3 cm plaque-type, erythematous lesion on his left ear of 4 weeks duration. Before seeking our care, he underwent a three-week course of itraconazole treatment, which failed. PCR analysis of a lesion biopsy confirmed Leishmania (L.) mexicana as the causative agent. At our clinic, we initiated systemic therapy with miltefosine, with partial healing. After his return to Mexico, he received perilesionals antimonials which lead to healing.
Patient 3. A 33-year-old female from Germany, presented with a 20-week history of a skin alteration following her travel to Guatemala, followed by southern Chiapas in Mexico (Tapachula), for tourism. The onset of two papules on her arm she first noticed in Unión Juárez. PCR analysis of a lesion biopsy confirmed Leishmania (L.) mexicana as the causative agent. She was treated with perilesional antimonials and is currently undergoing post-treatment follow-up.
Despite the fact that these are merely three cases of American Cutaneous Leismaniasis imported from Mexico, their emergence signifies a noteworthy escalation at our clinic. To put this into perspective, at our clinic, only a total of three imported Leishmania cases from Mexico have been observed since 2000, in the years 2007, 2018, and 2022, respectively. In the last five years, the GeoSentinel network has seen 23 patients with CL acquired in Mexico (although 3 of these patients had also visited other Central American countries). Notably 9 of these 23 patients were diagnosed in the last 12 months.
We hypothesize that this uptick is linked to an increase in cases in the region.1,2,3,4,5 According to WHO data, in Mexico in 2022, the rates of reported CL were the highest rates ever reported since 2005.
1 According to local epidemiological data from 2021 to 2023 from the Mexican Ministry of Health, Mexico has experienced an exponential growth in the number of reported CL cases. According to this data, at the close of 2021, Mexico had 136 cases of CL, with the state of Quintana Roo, accounting for 15 of those cases.3 In the following year, the cumulative count for 2022 surged to 954 cases (775 cases in men). The state of Quintana Roo recorded the majority with 500 cases (428 cases in men).4 Progressing to 2023, the accumulated number of cases for the year in Mexico further escalated to 1128 (958 cases in men). Once again, Quintana Roo remained the state with the highest number of cases, contributing 791 cases to the national figure (671 cases in men).5 This may be primarily linked to environmental changes in the region, including the construction and subsequent deforestation associated with the ‘Tren Maya’ project, something that would explain the rise in cases disproportionally affecting men. Furthermore, the construction of the ‘Tren Maya’ has been previously implicated by Mexican health authorities in Quintana Roo as the source of the outbreak.2 The first 2 patients in our report may have encountered these altered environments, as they were near ‘Tren Maya’ areas. The environmental alterations are likely contributing to an increase in vector-borne diseases, as they alter the natural habitats of reservoirs and vectors and potentially increase human exposure.
References
World Health Organization. Global Health Observatory data repository. Number of cases of cutaneous leishmaniasis reported. Data by country. Published 01.11.2023. Accessed: 20.12.2023. Available from: https://apps.who.int/gho/data/node.main.NTDLEISHCNUM?lang=en
Vitela N. El contagio que afecta a los obreros del Tren Maya. Reforma. Published: 08.02.2023. Accessed: 20.12.2023. Available from: https://www.reforma.com/el-contagio-que-afecta-a-los-obreros-del-tren-maya/ar2549253
Dirección General de Epidemiología. Sistema Nacional de Vigilancia Epidemiológica. Sistema Único de Información. Boletín Epidemiológico Semana 52, 2021. Secretaría de Salud. México. 2021; 37(53):42. Available from: https://www.gob.mx/cms/uploads/attachment/file/693135/sem52.pdf
Dirección General de Epidemiología. Sistema Nacional de Vigilancia Epidemiológica. Sistema Único de Información. Boletín Epidemiológico Semana 52, 2022. Secretaría de Salud. México. 2022; 37(53):46. Available from: https://www.gob.mx/cms/uploads/attachment/file/792216/sem52.pdf
Dirección General de Epidemiología. Sistema Nacional de Vigilancia Epidemiológica. Sistema Único de Información. Boletín Epidemiológico Semana 49, 2023. Secretaría de Salud. México. 2023; 37(53):44. Available from: https://www.gob.mx/cms/uploads/attachment/file/877087/BE_SE49.pdf
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Andreas Lindner, MD, Gabriela Equihua Martinez, MScPH, and Cristina Moreno Del Castillo, MScIH of the BER site have recently identified three patients who acquired cutaneous leishmaniasis in Mexico. Since this is a popular tourist destination, we want you to be aware of this risk and to be on the watch for patients returning from Mexico with this disease. Full details below.
Imported American Cutaneous Leishmaniasis – Germany ex Mexico
From April to August 2023, the Institute of International Health at Charité University Medicine in Berlin, Germany, a member of the GeoSentinel network, diagnosed three unrelated cases of imported cutaneous leishmaniasis (CL) in patients exposed in southeastern Mexico.
Patient 1. A 31-year-old female originally from Russia currently residing in Tulum, Quintana Roo, Mexico, presented to our clinic with a 2 cm ulcerative skin lesion on her knee of 15 weeks duration that had been previously confirmed as leishmaniasis in Mexico through microscopy. A PCR analysis of a lesion biopsy at our Institute confirmed Leishmania (L.) mexicana as the causative agent. Initially, she underwent systemic ketoconazole therapy; however, a reevaluation after three months indicated treatment failure. Subsequently, she received additional treatment with perilesional antimonials in Mexico, which successfully led to the lesion’s healing.
Patient 2. A 23-year-old male originally from Bacalar, Quintana Roo, Mexico who was travelling through Europe, presented with a 3 cm plaque-type, erythematous lesion on his left ear of 4 weeks duration. Before seeking our care, he underwent a three-week course of itraconazole treatment, which failed. PCR analysis of a lesion biopsy confirmed Leishmania (L.) mexicana as the causative agent. At our clinic, we initiated systemic therapy with miltefosine, with partial healing. After his return to Mexico, he received perilesionals antimonials which lead to healing.
Patient 3. A 33-year-old female from Germany, presented with a 20-week history of a skin alteration following her travel to Guatemala, followed by southern Chiapas in Mexico (Tapachula), for tourism. The onset of two papules on her arm she first noticed in Unión Juárez. PCR analysis of a lesion biopsy confirmed Leishmania (L.) mexicana as the causative agent. She was treated with perilesional antimonials and is currently undergoing post-treatment follow-up.
Despite the fact that these are merely three cases of American Cutaneous Leismaniasis imported from Mexico, their emergence signifies a noteworthy escalation at our clinic. To put this into perspective, at our clinic, only a total of three imported Leishmania cases from Mexico have been observed since 2000, in the years 2007, 2018, and 2022, respectively. In the last five years, the GeoSentinel network has seen 23 patients with CL acquired in Mexico (although 3 of these patients had also visited other Central American countries). Notably 9 of these 23 patients were diagnosed in the last 12 months.
We hypothesize that this uptick is linked to an increase in cases in the region.1,2,3,4,5 According to WHO data, in Mexico in 2022, the rates of reported CL were the highest rates ever reported since 2005.
1 According to local epidemiological data from 2021 to 2023 from the Mexican Ministry of Health, Mexico has experienced an exponential growth in the number of reported CL cases. According to this data, at the close of 2021, Mexico had 136 cases of CL, with the state of Quintana Roo, accounting for 15 of those cases.3 In the following year, the cumulative count for 2022 surged to 954 cases (775 cases in men). The state of Quintana Roo recorded the majority with 500 cases (428 cases in men).4 Progressing to 2023, the accumulated number of cases for the year in Mexico further escalated to 1128 (958 cases in men). Once again, Quintana Roo remained the state with the highest number of cases, contributing 791 cases to the national figure (671 cases in men).5 This may be primarily linked to environmental changes in the region, including the construction and subsequent deforestation associated with the ‘Tren Maya’ project, something that would explain the rise in cases disproportionally affecting men. Furthermore, the construction of the ‘Tren Maya’ has been previously implicated by Mexican health authorities in Quintana Roo as the source of the outbreak.2 The first 2 patients in our report may have encountered these altered environments, as they were near ‘Tren Maya’ areas. The environmental alterations are likely contributing to an increase in vector-borne diseases, as they alter the natural habitats of reservoirs and vectors and potentially increase human exposure.
References
World Health Organization. Global Health Observatory data repository. Number of cases of cutaneous leishmaniasis reported. Data by country. Published 01.11.2023. Accessed: 20.12.2023. Available from: https://apps.who.int/gho/data/node.main.NTDLEISHCNUM?lang=en
Vitela N. El contagio que afecta a los obreros del Tren Maya. Reforma. Published: 08.02.2023. Accessed: 20.12.2023. Available from: https://www.reforma.com/el-contagio-que-afecta-a-los-obreros-del-tren-maya/ar2549253
Dirección General de Epidemiología. Sistema Nacional de Vigilancia Epidemiológica. Sistema Único de Información. Boletín Epidemiológico Semana 52, 2021. Secretaría de Salud. México. 2021; 37(53):42. Available from: https://www.gob.mx/cms/uploads/attachment/file/693135/sem52.pdf
Dirección General de Epidemiología. Sistema Nacional de Vigilancia Epidemiológica. Sistema Único de Información. Boletín Epidemiológico Semana 52, 2022. Secretaría de Salud. México. 2022; 37(53):46. Available from: https://www.gob.mx/cms/uploads/attachment/file/792216/sem52.pdf
Dirección General de Epidemiología. Sistema Nacional de Vigilancia Epidemiológica. Sistema Único de Información. Boletín Epidemiológico Semana 49, 2023. Secretaría de Salud. México. 2023; 37(53):44. Available from: https://www.gob.mx/cms/uploads/attachment/file/877087/BE_SE49.pdf