Leishmaniasis recidivans mimicking lupus vulgaris

Giant Lupus Vulgaris with Negative T-SPOT.TB, a Case Report and Literature Review

Lupus vulgaris is a paucibacillary form of cutaneous tuberculosis (CTB) which is accounting for 1–2% of all tuberculosis cases. Here, we report a rare huge lupus vulgaris misdiagnosed as sarcoidosis for 11 years. A 65-year-old man presented to dermatology outpatient with a large asymptomatic erythematous plaque and erosions on his neck. Sarcoidosis was initially diagnosed on the basis of negative interferon-gamma release tests and biopsies of lymph nodes and lesions. The patient was treated with long-term oral steroid and immunosuppressive agents, but the lesions expanded gradually. Lupus vulgaris was finally diagnosed by combining molecular detection and mycobacterial culture. The skin lesions were resolved after six months of standard antituberculosis therapy. We report this case to analyze the reasons for the misdiagnosis and review-related literature to further provide experience for the diagnosis and treatment of cutaneous tuberculosis with negative T-SPOT.TB.

Lupoid cutaneous leishmaniasis: a case report

Background

Lupoid cutaneous leishmaniasis (CL) is a rare form of CL having a striking resemblance to other granulomatous cutaneous conditions of infectious or inflammatory origin. The authors present a patient with a facial lupoid CL and discuss the diagnostic tools of this parasitological infection, the main differential diagnosis, and treatment.

Case report

A 54-year-old Tunisian woman, with no past medical history of lupus erythematosus or infectious disease, presented with a 3-month history of a slowly enlarging erythematous and infiltrated plaque, extending over the nose, the right cheek, and the internal aspect of the right lower eyelid. Microscopic examination of a parasitological smear showed numerous leishmania in their amastigote form, inside monocytes, confirming the diagnosis of CL. Clinical aspect was in favor of lupoid CL. The patient was cured by fluconazole 200 mg/day for 6 weeks after pancreatic intolerance with intramuscular meglumine antimoniate (60 mg/kg/day for 7 days), and no response to doxycycline (200 mg/day for 6 weeks).

Discussion

Lupoid CL is easily suspected in countries in which there is an endemic of leishmaniasis. In countries where there isn’t an endemic, although rarely observed, this diagnosis should also be kept in mind in front of an infiltrated facial lesion of a tuberculoid aspect on histology, especially when there is a positive travel history to an area in which there is an endemic.

A rare case of leishmaniasis recidiva cutis evolving for 31 years caused by Leishmania tropica

A 64-year-old woman presented with erythematous, infiltrative plaques with a central atrophic area on both zygomatic regions. Several yellow-reddish papules were seen at the periphery of the plaques and showed an "apple-jelly" color on diascopy (Fig. 1). No visceral involvement was detected. The past medical history revealed that, at 3 years of age, she had developed an "Oriental sore" on both cheeks that healed with permanent scars. Thirty years later, she noticed an erythematous patch around the scars. She reported a hospital admission 22 years earlier for cutaneous leishmaniasis (CL); this was treated with pentavalent antimonial therapy for 10 days with partial improvement, when she refused further treatment. The lesions worsened in the summer and gradually became disfiguring, which prompted her to seek medical consultation. Laboratory findings were normal. Leishmania antibody titers were negative. Tissue samples were obtained by biopsy from the border of the lesion for culture, polymerase chain reaction (PCR), and histopathologic examination. Histology revealed a dermal infiltrate with tuberculoid granulomas surrounded by lymphocytes, histiocytes, and some plasma cells, but no caseation necrosis. A few Leishmania organisms were found on careful searching (Fig. 2). Leishmania tropica was identified by culture and PCR. A diagnosis of leishmaniasis recidiva cutis (LRC) was made on the basis of the anamnestic data together with the clinical, histopathologic, biologic, and molecular findings. Complete regression was achieved with meglumine antimoniate (Glucantime) given intramuscularly (15 mg Sb(V)/kg/day for 15 days) and cryosurgery with liquid nitrogen. No recurrence was noted during a 12-month follow-up period.

[Clinical and histological study of lupoid cutaneous leishmaniasis (16 cases)]

INTRODUCTION

Zoonotic cutaneous leishmaniasis (CL) is characterised by a major clinical polymorphism, especially the lupoid type. The aim of our study was to precise the anatomic and clinical particularities of this clinical form of CL.

MATERIALS AND METHODS

The present work was a prospective 1-year study. In all patients, the epidemiologic and clinical characteristics were identified, together with those regarding disease progression. Standard cutaneous biopsies were carried out for all study patients.

RESULTS

The lupoid form was observed in 15% of the patients. It was clinically characterised by a lupoid aspect with papular and squamous placard surrounded by a satellite papule, a short duration of disease progression (28 months in average) and a preferential localisation at the level of the face and the elbow, statistically proven. At the histological level, epidermic hyperplasia was found in 93.8% of the cases; an inflammatory polymorphic dermic infiltrate consisting of lymphocytes and plasmocytes was found in all patients; granulomas were noted in 50% of the cases, and isolated epitheloid cells were observed in the derm of 3 patients. Amastigotes were rarely observed.

DISCUSSION

In our series, the lupoid form was characterised with a short and non chronic evolution and two preferential sites for the affection: the face and the elbow. At the histological level, the lupoid type of CL appeared characterized by a high frequency of granuloma, usually organized, and rare amastigotes. However, the histology of authentic lupoid forms can be non granolomatosic.

[Chronic lupoid leishmaniasis. A rare differential diagnosis in Germany for erythematous infiltrative facial plaques]

Lupoid leishmaniasis is a unique form of cutaneous leishmaniasis characterized by unusual clinical features and a chronic relapsing course. Clinically and histologically it is similar to lupus vulgaris, which is thus the most important differential diagnostic consideration. All patients with granulomatous facial lesions coming from endemic areas or with a positive travel history should be suspected of having leishmaniasis. We describe a 59-year-old woman with facial lupoid leishmaniasis.

Leishmaniasis cutánea

Leishmaniases are diseases caused by infection by protozoa of the genus Leishmania. Cutaneous leishmaniasis caused by Leishmania infantum is frequent in Spain, especially in certain geographic areas. Diagnosis of cutaneous leishmaniasis is difficult because of the varied symptoms and because making cultures of this parasite is complicated. There are also different therapeutic, medical and surgical options, none of which is fully satisfactory. We review the most significant agents of cutaneous leishmaniasis in Spain.

A Case of Mucocutaneous Leishmaniasis

Leishmaniasis is prevalent in most warm-climate areas of the world. We describe a long-undiagnosed case of mucocutaneous leishmaniasis in Italy that might have been contracted in Costa Rica. The patient's signs and symptoms included granulomatous-like lesions on the forehead and legs, nasal obstruction accompanied by serous and crusted rhinorrhea, and diffuse granulomatous-like lesions in the septum and turbinates. The patient was treated with three on-off cycles of itraconazole. At the 1-year follow-up, all his lesions had nearly disappeared.