A 38-year-old man from Brazil returns to clinic after a 4-year stay in the Amazon basin. He had a self-healed cutaneous ulcer on his forearm during that stay. He now presents with progressive nasal congestion, epistaxis, and progressive destruction of the nasal septum with collapse of nasal cartilage ("tapir nose"), palatal perforation, and granulomatous ulceration extending to the oropharynx and larynx. Biopsy of the mucosal lesion shows granulomatous inflammation with sparse amastigotes (Leishman-Donovan bodies) in macrophages on Giemsa stain. The condition marked **B** in the diagram is most likely present. Which of the following is the MOST APPROPRIATE first-line treatment for this condition?
A. Miltefosine 2.5 mg/kg/day orally for 28 days
B. Sodium stibogluconate 20 mg/kg/day IV/IM for 28 days with ECG monitoring
C. Liposomal amphotericin B 3 mg/kg/day on days 1–5, 14, and 21 (total dose 20–40 mg/kg)
D. Pentamidine isethionate 4 mg/kg/day IV for 14 days
Explanation
Why Liposomal amphotericin B is right
Liposomal amphotericin B (3 mg/kg/day on days 1–5, 14, and 21; total dose 20–40 mg/kg) is the current first-line treatment for mucocutaneous leishmaniasis (espundia) caused by Leishmania (Viannia) braziliensis. It has replaced pentavalent antimonials due to superior efficacy in mucosal disease and a better safety profile (WHO Leishmaniasis Guidelines 2024; Mandell's Principles and Practice of Infectious Diseases 9e). The condition marked B — mucocutaneous leishmaniasis with progressive nasal septum destruction, palatal perforation, and oropharyngeal involvement — represents advanced mucosal disease that requires the most potent and reliable agent.
Why each distractor is wrong
Sodium stibogluconate 20 mg/kg/day IV/IM for 28 days: This pentavalent antimonial is an alternative treatment, but it is no longer first-line for mucosal disease due to inferior efficacy in mucosal leishmaniasis, cardiotoxicity, pancreatotoxicity, and the need for ECG monitoring. It has been superseded by liposomal amphotericin B.
Miltefosine 2.5 mg/kg/day orally for 28 days: Although miltefosine is an oral alternative for leishmaniasis, it is not preferred as first-line for mucosal disease. It is typically reserved for cutaneous disease or as a second-line option when parenteral therapy is contraindicated.
Pentamidine isethionate 4 mg/kg/day IV for 14 days: Pentamidine is not a standard treatment for mucocutaneous leishmaniasis. It is used for Pneumocystis jirovecii prophylaxis and some protozoal infections, but it is not indicated for leishmaniasis.
High-YieldNEET PG
Liposomal amphotericin B is now the gold-standard first-line therapy for mucocutaneous leishmaniasis (espundia), replacing antimonials due to superior efficacy and safety in mucosal disease.
WHO Leishmaniasis Guidelines 2024; Mandell's Principles and Practice of Infectious Diseases 9e
Practice similar questions
Sign up free to access AI-powered MCQ practice with detailed explanations and adaptive learning.
