This case highlights the growing challenge and significance of considering leishmaniasis in physicians' diagnostic considerations in non-endemic regions, including the United States. In the recent years, CL has a rising global prevalence due to increasing migration from endemic areas, which requires healthcare professionals around the world to be able to effectively recognize leishmaniasis and its complications [7].

In our case, the unusual location of the lesions led to a delay in diagnosis and management. Periorbital lesions in cutaneous leishmaniasis are thought to be rare due to the movement of the eyelids which deters the bite of the fly vector [8, 9]. In a study of over 1,700 CL lesions of patients in Turkey, only 1.93% of lesions were located on the eyelid and the periorbital region [3]. Additionally, adnexal Leishmaniasis commonly presents as a chalazion-like lesion which can often bear resemblance to a multitude of other cutaneous lesions such as those from recurrent chalazion, ulcerative basal cell carcinoma, granulomatous blepharitis, and infected infundibular cysts [3, 10,11,12].

The diagnosis of cutaneous leishmaniasis is classically made with a tissue biopsy, which allows for the identification of the microorganisms through staining or culture [13]. In recent years, PCR has also emerged as a critical tool in diagnosis, offering the option for molecular analysis of specimens, which can be pivotal in guiding treatment strategies [14]. The effectiveness of these diagnostic methods was particularly significant in this case, as they led to the identification of the causative agent as L. aethiopica.

L. aethiopica, one of the most understudied species of Leishmania, is the predominant strain endemic to Ethiopia [15], where up to 65% of the population in affected areas is reported to have either an active or past infection of leishmaniasis [16]. The identification of this species was crucial, as L. aethiopica is known for its slower healing time and reduced sensitivity to conventional treatment regimens [17]. This knowledge underscores the importance of accurate diagnosis and species identification in the effective management of leishmaniasis cases.

In selecting treatment regimens for Leishmaniasis, it's crucial to consider the specific Leishmania species, patient toxicity risk, and local medication availability. Historically, pentavalent antimonials were the standard first-line treatment. However, due to rising resistance concerns, the WHO has updated its standard of care to recommend liposomal amphotericin B [18]. Recently, systemic oral miltefosine has emerged as an alternative treatment. It is often better tolerated than amphotericin B, which is associated with renal insufficiency and other serious side effects. Initially developed for cancer therapy, miltefosine has since received Food and Drug Administration (FDA) approval for treating three specific species of New World leishmaniasis and has been shown to be effective against L. aethiopica in several small clinical trials [19,20,21]. In this case, our patient's successful treatment involved a 28-day course of miltefosine.

Lastly, this case highlights the diagnostic value of a prompt skin biopsy, which would have undoubtedly led to a sooner diagnosis and treatment for the patient, as well as avoided unnecessary laboratory tests, diagnostic images, and healthcare expenses. Patient education and clear communication of risks and benefits of such procedures must be effectively achieved in order to achieve optimal outcome for all parties.