Leishmaniasis acquired by travellers to endemic regions in Europe: A EuroTravNet multi-centre study

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Summary

Background

Leishmaniasis is a disease caused by protozoan parasites of the genus Leishmania. Clinical manifestations of leishmaniasis include cutaneous leishmaniasis (CL) and visceral leishmaniasis (VL). About 90% of cases occur in the tropics or subtropics but the disease is also endemic in the Mediterranean area. No systematic analysis on leishmaniasis in travellers visiting endemic areas in Europe is available.

Methods

Within the European travel medicine network EuroTravNet, we performed a retrospective analysis in travellers who acquired leishmaniasis within Europe diagnosed between 2000 and 2012.

Results

Forty cases of leishmaniasis (30 CL and 10 VL) were identified; the majority were acquired in Spain (n = 20, 50%), Malta and Italy (each n = 7, 18%). Median age was 48 years (range 1–79). Three of eight (37.5%) of the VL patients were on immunosuppressive therapy. The most frequent reason for travel was tourism (83%). Median duration of travel for patients with CL and VL was 2 weeks with ranges of 1–21 weeks in CL and 1–67 weeks in VL, respectively (P = 0.03).

Conclusions

Health professionals should include leishmaniasis in the differential diagnosis in patients returning from southern Europe – including short-term travellers – with typical skin lesions or systemic alterations like fever, hepatosplenomegaly and pancytopenia.

Introduction

Leishmaniasis is a disease caused by protozoan parasites which belong to the genus Leishmania. Currently, leishmaniasis occurs in all continents with the exception of Antarctica and is considered to be endemic in 88 countries. In Europe, leishmaniasis is endemic to the Mediterranean basin including countries like Macedonia, Croatia, Greece, Italy and Southern parts of France and the Iberian peninsula, where it is transmitted by sand flies of the genera Phlebotomus. Rodents and canines are important reservoirs. Leishmaniasis is characterised by a broad spectrum of clinical symptoms related to the two major manifestations of cutaneous leishmaniasis (CL) and visceral leishmaniasis (VL) that occur with a latency anywhere from a week to years [1], [2], [3], [4], [5], [6], [7].

The majority of persons affected with leishmaniasis live in endemic areas but travellers to endemic regions are also at risk, notably to South America and Central America [8], [9]. In Europe, leishmaniasis occurs as zoonotic cutaneous and visceral leishmaniasis caused by Leishmania infantum in the Mediterranean basin and as an anthroponotic cutaneous leishmaniasis caused by Leishmania tropica sporadically occurring in Greece [10]. It has been estimated that around 700 new cases of leishmaniasis occur in southern European countries [11]. In Spain, one third of patients hospitalised with leishmaniasis have been described to be co-infected with HIV [12]. Several case reports on leishmaniasis occurring in travellers to Mediterranean areas have been published [13], [14], [15], [16], [17]. However, no systematic analyses of leishmaniasis in travellers visiting endemic areas in Europe are available. This retrospective analysis characterises leishmaniasis in European travellers infected in Europe who presented to surveillance sites of the EuroTravNet network within the years 2000–2012.

Section snippets

Methods

This retrospective analysis was conducted within EuroTravNet (www.eurotravnet.eu), a sentinel surveillance network of currently 18 European travel/tropical medicine reference centres in 10 countries [18]. Travellers with CL and/or VL who acquired their infection in Europe between 2000 and 2012 were included into the analysis. Migrants from leishmaniasis-endemic areas outside Europe, persons with history of travel to endemic areas outside Europe as well as local persons living in endemic

Results

A total of 40 cases of leishmaniasis acquired by travellers within Europe were identified, including 30 patients with CL (27 confirmed and 3 probable) and 10 patients with VL. All patients were of Caucasian origin, born in Europe and their countries of residence were Germany (n = 28), Switzerland (n = 3), Norway (n = 4), The Netherlands (n = 2) and United Kingdom (n = 3). The median age of all patients was 48 years (range 1–79 years), 19 patients (48%) were female. Only one third (32%) was

Discussion

The present analysis of 40 travellers with leishmaniasis is, to the best of our knowledge, the largest study on leishmaniasis in tourists who acquired their infection in Europe. The majority of CL cases occurred in typical short term travellers spending a 1–3 weeks vacation at common tourist destinations of southern Europe including the Balearic Islands as well as Sicily and Peloponnese. Two of five patients with VL, for whom data on the duration of travel were available, spent 20 and 67 weeks

Conflict of interest

No conflict of interest to declare.

Acknowledgement

All authors have seen and approved the final manuscript. The authors declare no conflict of interests.

EuroTravNet (http://www.eurotravnet.eu) is the European Centre for Disease Prevention and Control (ECDC) corresponding network for tropical and travel medicine, funded through the public tenders OJ/2008/07/08-PROC/2008/019 and OJ/2010/03/16-PROC/2010/011. It has been created by grouping the European sites of GeoSentinel (http://www.geosentinel.org), the Global Surveillance Network of the

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