American Cutaneous Leishmaniasis – Case Series and a Narrative Discussion of the Cost-Effectiveness of Intralesional Therapy

American Cutaneous Leishmaniasis (ACL) is a neglected disease, endemic in some regions of the state of Paraná, such as the Ribeira Valley and the central and northern regions. Intralesional meglumine antimoniate (IL-MA) was approved by the Brazilian Ministry of Health in 2017 for the treatment of localized ACL. The following is a cost comparison of the intralesional strategy versus classic therapies, using as examples three patients from cities in the Curitiba macro-region treated at an infectious diseases reference service in Paraná. Patient 1 was a 78-year-old man, former farm worker, with hypertension, dyslipidemia, and a significant smoking history. The extent of the lesions on the left forearm (image 1) contributed to choosing systemic therapy: he received liposomal amphotericin B for 11 days, with a total dose of 2 grams. Patient 2, a 58-year-old male farm worker, had one lesion on the chest and another on the right knee (image 2). For him, a 28-day course of miltefosine 50 mg every 8 hours orally was chosen. Patient 3, a 51-year-old woman, smoker, and hypertensive, had a 4-cm lesion on the left leg (image 3). She received IL-MA in three sessions (20 days between the 1st and 2nd sessions, and 13 days between the 2nd and 3rd), at a dose of two ampoules (total of 3 grams) per session. In subsequent outpatient follow-ups, all three patients were considered cured of ACL at day 180 after treatment. None of the three patients experienced significant adverse events related to the regimens. The estimated treatment cost for Patient 1 was R$ 55,459.20 (considering R$ 1,386.48 as the price of one 50-mg ampoule). Patients 2 and 3 had estimated treatment costs of R$ 568.68 (one tablet at R$ 6.77 three times daily for 28 days) and R$ 28.38 (four ampoules at R$ 4.73), respectively. This comparison did not include the cost of hospital admission for Patient 1 nor outpatient visits for any of the three patients. The comparative analysis suggests that, when appropriately indicated (i.e., for few lesions or a single small lesion), IL-MA is a valid therapeutic option, with benefits not only for the individual patient but also financially for the treating service. Although simplistic, the comparison presented here used tangible data faithful to the routine of a tertiary infectious diseases hospital.