# How Common Is Imported Cutaneous Leishmaniasis in Romania? Two Case Reports

## TL;DR

Two cases of imported cutaneous leishmaniasis in Romania highlight the growing risk of the disease in non-endemic areas due to travel and climate change.

## Contribution

The paper presents two rare cases of imported cutaneous leishmaniasis in Romania, a non-endemic country, emphasizing diagnostic and therapeutic challenges.

## Key findings

- Two imported cases of cutaneous leishmaniasis were diagnosed in central Romania, with one confirmed via histopathology and PCR.
- Treatment with miltefosine and fluconazole showed clinical improvement, though one case had a secondary bacterial infection.
- The cases underscore the need for increased awareness and accurate diagnostics for leishmaniasis in non-endemic regions.

## Abstract

Background: Leishmaniasis is a vector-borne zoonotic disease caused by protozoa of the genus Leishmania. While it is endemic in the Mediterranean Basin and the Balkans, Romania remains a non-endemic country. However, climate change, increased international travel, and the documented presence of competent vectors (Phlebotomus spp.) have raised concerns about the potential emergence of autochthonous cases. Case Presentation: We report two cases of imported cutaneous leishmaniasis (CL) diagnosed in central Romania, a region without previously confirmed human or animal cases. The first case involved a 31-year-old male with a recent travel history to Spain, presenting with erythematous papules and plaques that evolved into ulcerated lesions. The diagnosis was confirmed histopathologically and by a PCR. Treatment with miltefosine was effective, with minimal hepatic toxicity and a sustained response at a six-month follow-up. The second case concerned an 11-year-old boy who had traveled to Elba, Italy. He developed ulcerative lesions that progressed rapidly and were complicated by Pseudomonas aeruginosa superinfection. Despite an initially negative smear, PCR testing of the skin lesion confirmed the presence of CL. Antifungal therapy with fluconazole led to clinical improvement; treatment was ongoing at the time of publication. Discussion: These cases highlight the diagnostic and therapeutic challenges associated with CL in non-endemic settings. The varied clinical evolution underscores the importance of considering leishmaniasis in the differential diagnosis of chronic, non-healing cutaneous lesions, particularly in patients with a travel history to endemic regions. Conclusions: Increased awareness among clinicians, supported by accurate diagnostic tools and public health surveillance, is essential to identify and manage imported leishmaniasis. Given the absence of a licensed vaccine and the growing risk of vector expansion in Eastern Europe, these cases support the WHO’s inclusion of leishmaniasis among the priority neglected tropical diseases targeted for intensified global control efforts by 2030.