Borderline Disseminated (Intermediate) Cutaneous Leishmaniasis: A Case-Based Approach to Diagnosis and Clinical Management in Pediatric Population

Background: Cutaneous leishmaniasis (CL) is a neglected tropical disease with diverse clinical manifestations, ranging from localized CL to severe forms such as diffuse CL and mucocutaneous leishmaniasis. Borderline disseminated CL (BDCL), an intermediate form, is characterized by multiple disseminated lesions and poses unique diagnostic and therapeutic challenges, especially in pediatric patients. This study explores pediatric BDCL to better understand its clinical presentation, diagnostic approaches and treatment outcomes. Methods: We report 4 pediatric cases of BDCL from Panama, identified through polymerase chain reaction and histopathological analysis. Species identification utilized polymerase chain reaction and heat shock protein 70 gene sequencing. Treatment included amphotericin B, meglumine antimoniate and miltefosine, with follow-up evaluations assessing lesion progression and treatment outcomes. Results: All patients exhibited multiple disseminated ulcerative and nodular lesions, with some involving mucosal sites. Species identification confirmed Leishmania guyanensis and Leishmania panamensis as causative agents. Two patients received meglumine antimoniate, achieving complete lesion resolution. Due to better tolerability, miltefosine was used in the remaining 2 patients, resulting in slower but complete lesion resolution over time. Amphotericin B demonstrated limited efficacy. Conclusions: Pediatric BDCL presents significant diagnostic and therapeutic challenges due to variable immune responses, clinical presentations and species-related treatment resistance. While meglumine antimoniate and miltefosine showed promising results, amphotericin B was less effective. Further research is needed to establish optimized treatment protocols for pediatric BDCL, considering species-specific responses and pharmacokinetic and pharmacodynamic differences in children.