Skin biopsy / Ulcer scrapings / Bone marrow aspirate

Cutaneous leishmaniasis

• A clinical history suggestive of cutaneous leishmaniasis is characterized by the appearance of one or more lesions, typically on uncovered parts of the body. The face, neck, arms and legs are the commonest sites
• In localized cutaneous leishmaniasis, a typical lesion starts as a raised papule at the site of inoculation
• It grows over several weeks to reach a final size of a nodule or a plaque
• A crust develops centrally, covering an ulcer with a raised edge and variable surrounding

Visceral leishmaniasis

Fever, hepatosplenomegaly, weight loss, pancytopenia

Skin biopsy / Ulcer scrapings

• Clean the whole lesion and border using 70% alcohol at least 3 minutes before injecting the anaesthetic
• Inject 0.1-0.5 ml of lidocaine with adrenaline, using a short 23-gauge needle thereby creating a blanching area
• It is not necessary to anaesthetize the whole lesion
• For lesions on fingers or toes use lidocaine without adrenaline (necrosis risk)
• Pinch strongly the lesion to further prevent bleeding
• Remove the crust, remove blood with a gauze, scratch firmly (using a sterile scalpel with a short-angle curved blade) the border and the centre of the lesion until tissue material is visible on the blade
• Gently move the blade on the surface of a slide to deposit a thin layer of the scraped material. Repeat the procedure on different parts of the anaesthetized zone until at least half of the surface of each of three slides is covered with material

Bone marrow aspirate

• The preferred anatomic site for BM aspiration is the posterior iliac crest
• Place the patient either in a prone position or in the right/left lateral decubitus position, with the knees flexed at 45°
• The biopsy site is identified by careful palpation of anatomic landmarks
• Clean the area using an appropriate antiseptic solution (e.g., chlorhexidine or povidone-iodine solution) and drape the site
• First infiltrate the skin slowly with local anesthetic (1%-2% buffered lidocaine)
• Once the skin is numb, the subcutaneous tissue and periosteum are infiltrated with 2 to 5 mL of lidocaine, depending on the thickness of the subcutaneous tissue and the depth of the periosteum
• Sufficient time (3-5 minutes) is given for the full anesthetic effects to develop
• The adequacy of anesthesia can be tested by gently probing the periosteum with the tip of a needle and questioning the patient about any pain
• Introduce the needle and bring it into contact with the periosteum. The patient should feel only a sensation of pressure at this point
• Using gentle but firm pressure, advance the needle while rotating it in an alternating semicircular clockwise–counterclockwise motion
• Once the needle passes through the cortical bone and enters the marrow cavity, there is generally a decrease in resistance, and the needle should stay in place without being held
• Remove the stylet from the needle, warn the patient that her or she may feel pain when bone marrow is being aspirated, and aspirate approximately 0.5 to 1 mL of bone marrow into the syringe
• Evaluate the aspirate immediately by spreading a drop of the sample on a slide or dish to observe bony spicules, which will be visible as irregularities in the smooth surface of the blood (If spicules are not present, it may be necessary to repeat the procedure by inserting the needle further into the bone or repeat the procedure at a new site)
• Prepare samples immediately following aspiration; initial smears should be made with aspirate directly from the plain collecting syringe; remaining aspirate should be placed into tubes containing EDTA
• Bone marrow smears should be prepared immediately following aspiration

• Skin biopsy / Ulcer scrapings
• Gloves
• 70% alcohol
• Local anaesthetic (lidocaïne 1%)
• 23-gauge needle
• Sterile scalpel
• Gauze
• Slides

• Bone marrow aspirate
• Sterile gloves
• 10 ml or 20 ml plastic syringe (provide adequate negative pressure)
• Antiseptic solution (chlorhexidine, poidone iodine)
• Local anaesthetic (lidocaïne 1%)
• Drape
• Aspiration needle
• Slides

It is mandatory to obtain a parasitological confirmation of the diagnosis before engaging in a systemic, potentially highly toxic antileishmanial treatment