Case report and literature review of leishmaniasis as a cause of leg ulceration in the United Kingdom

Non-Endemic Leishmaniases Reported Globally in Humans between 2000 and 2021—A Comprehensive Review

Leishmaniases are human and animal parasitic diseases transmitted by phlebotomine sand flies. Globalization is an important driver of the burden and in the current dynamics of these diseases. A systematic review of articles published between 2000 and 2021 was conducted using the PubMed search engine to identify the epidemiology and clinical management of imported human leishmaniases as a fundamental step to better manage individual cases and traveler and migrant health from a global perspective. A total of 275 articles were selected, representing 10,341 human imported cases. Identified drivers of changing patterns in epidemiology include conflict and war, as well as host factors, such as immunosuppression, natural and iatrogenic. Leishmania species diversity associated with different clinical presentations implies diagnostic and treatment strategies often complex to select and apply, especially in non-endemic settings. Thus, diagnostic and management algorithms for medical clinical decision support are proposed. Increased surveillance of non-endemic cases, whether in vulnerable populations such as refugees/migrants and immunocompromised individuals or travelers, could improve individual health and mitigate the public health risk of introducing Leishmania species into new areas.

Tetanus in patients with chronic wounds - are we aware?

The incidence of tetanus in patients with wounds is unknown; however, recently concern has been raised over the proportion of tetanus cases in which a chronic wound is the portal of entry for Clostridium tetani. Varicose ulcers, dermatosis and necrosed tumours are estimated to be the point of entry for C. tetani spores in 11-14% of three cases. Of diabetic patients in the USA who contracted tetanus, a diabetic foot ulcer was responsible in 25% of cases despite this chronic wounds have yet to be considered as a risk factor for tetanus. An audit was undertaken and a survey devised to form the basis of the data collection to assess if patients with chronic wounds are up-to-date in accordance with the tetanus immunisation programme. Over a 5-day period, the data were prospectively collected and the tetanus status of a 100 patients retrospectively analysed. The status was then compared with general practitioner (GP) records via telephone follow-up. One hundred patients (n = 100) were available in the audit period, with the majority being male (n = 51). The age range was 22-91 years old (median 70 years). Nearly half of the samples (n = 48) were diabetic, with the majority of patients (n = 35) having venous leg ulcers. Only 15% had a biopsy of their wound. The duration of wounds varied from 1 to 480 months. Patients were asked to confirm their tetanus status. Almost half of the patients were unsure of their tetanus status 48% (n = 48), almost a third 30% (n = 30) thought they were not covered and 22% (n = 22) thought they were up-to-date. After confirming with the GP records, the results were as follows: almost half of the patients, 43% (n = 43) were not covered, 33% (n = 33) were up-to-date, 13% had no immunisation records available at the GPs, 10% had no GP contact details and 1% no contact was possible. Currently, tetanus prophylaxis is given based on the vaccination history of the patient but as identified that this can prove to be unreliable. With the burden of chronic wound and ageing population set to increase, levels of protection amplify the risk of tetanus faced by those suffering from chronic wounds. Strict caution should be taken in those patients who were born before the national childhood vaccination programme, implemented in 1961. Moreover, every effort should be made to ensure that such individuals complete their primary course. By ensuring each patient is actively immunised, protection against tetanus, a potential killer, is provided.