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

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.

Keywords: Romania; case report; cutaneous leishmaniasis.

Figure 1

Erythematous, infiltrated plaques (A,B) and nodules © located on the lower limbs. The lesions appeared relatively well defined, though with irregular borders and a mildly edematous aspect. They ranged in size from 3 to 5 cm, with some showing central ulceration (C,D).

Figure 2

Clinical appearance of the cutaneous lesions one month after the completion of treatment. Hyperpigmented plaques with mild infiltration, likely reflecting underlying dermal fibrosis, and central scarring consistent with re-epithelialized ulcerations. The lesions remained stable in size, with no signs of local inflammation (A–C).

Figure 3

Clinical appearance of the cutaneous lesions in May 2025; photos provided by the patient.

Figure 4

(a,b) Erythematous, indurated, and warm infiltrated plaques with poorly defined margins and progressive peripheral extension. Central areas exhibited necrotic ulcerations covered by adherent yellow fibrino-necrotic material. Clinical aspect at 8 weeks from onset. (c,d) Stabilization of infiltrated plaques, with reduction in periulcerative inflammation and partial regression of peripheral erythema, despite persistence of vasculitic-like appearance. Central ulcerations had increased in both size and depth, with continued presence of fibrino-necrotic debris. Clinical aspect at 10 weeks from onset.