Complex Cutaneous Leishmaniasis in Pregnancy

A report describes a case of a previously healthy 30-year-old G4P3004 who presented to prenatal care at 31 weeks of gestation with a 4-week history of large crusted and ulcerated plaques on her lower extremities and face. She documented a history of residing in the wilderness and near bodies of water. 

Initial examination revealed her to be afebrile. Skin examination showed 2 to 6 cm tender, crusted plaques on the left cheek, right lateral knee, and left medial thigh with peripheral hyperkeratosis, satellite papules, and central ulceration with purulent drainage and no mucosal involvement. Laboratory studies revealed no abnormalities in complete blood count, chemistries, or liver function tests. She received oral clindamycin and topical mupirocin.

She presented again three weeks later with interval development of a new skin lesion. Her routine prenatal laboratory tests came back negative, and she was suspected of leishmaniasis based on the lesion morphology and travel history. 

An obstetrical ultrasound revealed an enlarged placenta, normal amniotic fluid index, and growth-restricted fetus, and the patient received a course of betamethasone for fetal lung maturity. Her ultrasound revealed no visceral involvement.

While awaiting diagnostic studies, the patient received presumptive treatment for leishmaniasis with liposomal amphotericin B (3 mg/kg per day) for seven days. She underwent daily renal and liver function tests and electrolyte monitoring. 

A repeat ultrasound showed symmetrical intrauterine growth restriction (<1%) with mildly resistive umbilical artery Doppler studies and a thickened, 7.5 cm heterogeneous placenta.

The skin biopsy revealed pseudoepitheliomatous hyperplasia with neutrophilic microabcesses, plasma cells, and small intracytoplasmic organisms on Giemsa staining consistent with leishmaniasis. PCR testing also confirmed Leishmaniasispanamensis speciation. Stool ova and parasite cultures were positive for Giardia lamblia; thus, the patient received metronidazole. 

During hospitalization, the patient developed preeclampsia without severe features. At 35 weeks and six days of gestation, fetal heart rate monitoring became nonreassuring; thus, the patient underwent cesarean delivery and delivered a viable female infant weighing 1815 g. Placental pathology showed massive perivillous fibrin deposition (maternal floor infarction) covering 70% of the placental disk sampled without evidence of leishmania infection.

During follow-up, the patient showed minimal clinical response to amphotericin B and thus was transitioned to fluconazole therapy at a daily dosage of 600 mg. After three months of continuous therapy, her skin lesions had healed, and she had no new lesions, with decreased pain.

Zachek CM, et al. Complex cutaneous leishmaniasis in pregnancy.AJOG. 2023;229(3):P337-339. DOI:https://doi.org/10.1016/j.ajog.2023.02.027