CUTANEOUS LEISHMANIASIS IN ISRAEL 2016 - AN UPDATE

INTRODUCTION: Leishmaniasis is endemic in Israel and is increasing in its frequency. The pathogens that cause cutaneous leishmaniasis (CL) in Israel are Leishmania major (L. major) and Leishmania tropica (L. tropica). In recent years, there have been significant changes in the distribution of these species. L. major is endemic mainly in the Negev, Arava and the Beit She'an Valley. L. tropica is endemic in Tiberias, northern Sea of Galilee, Samaria and in the vicinity of Jerusalem such as at Kfar Adumim, Ma'ale Adumim and Anathoth (north-east of Jerusalem). In addition, there is imported Leishmania Braziliensis (L. braziliensis) from Israeli travelers, originating mainly from the Amazon region of Bolivia. The clinical course of CL and the best treatment varies and is determined by the leishmania species. Among the endemic pathogens in Israel, the clinical course of L. tropica can be more severe, last longer and may be more resistant to treatment in comparison to L. major. However, imported leishmaniasis carries the risk of muco-cutaneous involvement and it is therefore important to identify the exact species to determine the appropriate treatment. The main treatment options for endemic cutaneous leishmaniasis are topical treatment with paromomycin ointment, liquid nitrogen, or intra-lesional injectable sodium stibogluconate (pentostam). Occasionally, there are cases of CL that require systemic therapy, such as in cases that lack response to local treatment, cases of multiple lesions or if affected areas of the body are such that local treatment cannot be applied. The most common systemic treatment is intravenous sodium stibogluconate (pentostam). This treatment may cause serious side effects. Therefore, in recent years we use intravenous liposomal amphotericin B (AmBisome) as the first line treatment, with a high success rate. Standard treatment for imported L. braziliensis is intravenous therapy in order to prevent its spread to the naso-pharynx, which can cause permanent destruction of the cartilage in these areas. The drug of choice is intravenous liposomal amphotericin B, and in cases of treatment failure, intravenous sodium stibogluconate (pentostam) can be used. This year the use of oral miltefosine tablets was also approved in Israel for cases of cutaneous leishmaniasis.