Epidemiological and Clinical Aspects of Cutaneous and Mucosal Leishmaniases in Portugal: Retrospective Analysis of Cases Diagnosed in Public Hospitals and Reported in the Literature between 2010 and 2020.

Leishmania infantum, a zoonotic vector-born parasite, is endemic in the Mediterranean region, presenting mostly as visceral (VL), but also as cutaneous (CL) and mucosal leishmaniasis (ML). This study aimed to describe the epidemiological and clinical aspects of the CL and ML cases diagnosed in mainland Portugal between 2010 and 2020. Collaboration was requested from every hospital of the Portuguese National Health System. Cases were screened through a search of diagnostic discharge codes or positive laboratory results for Leishmania infection. Simultaneously, a comprehensive literature search was performed. Descriptive statistics and hypothesis testing were performed using IBM® SPSS® Statistics. A total of 43 CL and 7 ML cases were identified, with a predominance of autochthonous cases (86%). In CL, immunosuppressed individuals constituted a significant proportion of patients (48%), and in this group, disseminated CL (22%) and simultaneous VL (54%) were common. In autochthonous cases, lesions, mostly papules/nodules (62%), were frequently observed on the head (48%). The approach to treatment was very heterogeneous. ML cases were all autochthonous, were diagnosed primarily in older immunosuppressed individuals, and were generally treated with liposomal amphotericin B. The findings suggest a need for enhanced surveillance and reporting, clinical awareness, and diagnostic capacity of these forms of leishmaniasis to mitigate underdiagnosis and improve patient outcomes. A holistic One Health approach is advocated to address the multifaceted challenges posed by leishmaniases in Portugal and beyond.

Optic Neuritis and Vertebral Osteomyelitis: An Uncommon Presentation of Cat-Scratch Disease.

In cat-scratch disease (CSD), hematogenous spread may result in atypical presentations. Ocular manifestations develop in a minority of patients, with treatment being important in reducing long-term visual sequelae. Bone infection is rare. We present the case of a 52-year-old woman, with close contact with cats, reporting acute unilateral blurred vision and presenting papilledema, optic disc pallor, and peripapillary hemorrhage. Etiologic study of optic neuritis revealed an elevated positive Bartonella IgG; hence, treatment for CSD with doxycycline plus rifampin and corticosteroids was started. Concomitant lumbar pain of increasing intensity warranted magnetic resonance imaging, which revealed L3-L4 vertebral osteomyelitis with spondylodiscitis. Given the temporal link with CSD diagnosis and the significant clinical improvement since its treatment was started, an etiologic link was presumed and antibiotics were prolonged. This case stands out for the presence of distinct atypical CSD manifestations in the same patient. Further studies are needed to determine the optimal treatment for rare manifestations, particularly bone infection.

Complicated Cutaneous Leishmaniasis in a Patient under Combined Immunosuppression.

Species associated with visceral leishmaniasis, such as L. infantum, may be responsible for cutaneous leishmaniasis (CL), particularly in the Mediterranean region. In immunosuppressed hosts, classification as complicated CL is essential, as the risk of mucosal leishmaniasis warrants systemic therapy. We report the case of a forty-seven-year-old male living in Portugal, with Fabry disease and receiving immunosuppressive treatment with adalimumab and methotrexate for Crohn's disease. There was no travel history outside of Europe. He presented a two-year-old, 5.5 cm plaque with a well-defined hyperkeratotic elevated border and central, painless ulceration on his back. The biopsy revealed parasites inside macrophages suggestive of Leishmania, and PCR identified the species as L. infantum. A biopsy via nasal endoscopy excluded mucosal involvement. Classification as complicated CL dictated treatment with liposomal amphotericin B and subsequent topical paramomycin. The rarity of CL in Portugal may delay its diagnosis, especially in autochthonous infections. Treatment choice is complicated by the heterogeneity of drugs available worldwide. As the global prevalence of CL increases, it is important to be aware of this diagnosis.

Relapsing COVID-19 in a Patient With Non-Hodgkin Lymphoma on Chemotherapy.

Hematologic malignancies and chemotherapy are risk factors for COVID-19 progression and mortality. Immunocompromised hosts, particularly those with severe B-cell depletion, can shed viable viruses for extended periods, which can lead to persistent infection. We present the case of a 73-year-old male with diffuse large B-cell lymphoma (stage IV-B) under curative immunochemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). After the first episode of mild COVID-19, he developed two severe relapses following the third and fourth cycles of R-CHOP. Lung CT scans performed in both episodes showed new-onset ground-glass infiltrates and fibrosis of previously affected pulmonary segments. In light of similar semiquantitative SARS-CoV-2 viral loads between episodes, without further risk exposure or microbiological findings, persistent COVID-19 with severe clinical relapses was assumed and successfully treated with polyclonal immunoglobulin and remdesivir. Whole-genome sequencing was performed in all samples, confirming the same specimen, which belonged to the B.1.177 lineage. This case stands out for the unusually long viral persistence and the various relapses of severe COVID-19 related to the worsening immune status with each immunochemotherapy cycle.