Unusual presentation of cutaneous leishmaniasis

Introduction

Cutaneous leishmaniasis is the most common type of leishmaniasis present in the kingdom of Saudi Arabia. The most important factor is that cutaneous leishmaniasis is protean in its manifestation and may mimic many other pathological skin conditions. The first step is to maintain a high index of suspicion for this disorder, when a native resident develops a nonhealing skin lesion of 2 or more week′s duration[1] on exposed sites. One criteria to confirm the diagnosis is to demonstrate the parasites in the lesions.

Case Report

A 36- year-old Pakistani male presented to Dermatology clinic with a thick verrucous plaque over lateral aspect of left leg of two months duration. On examination a 4 inch by 3 inch indurated violaceous-red plaque with papillomatous surface was seen over the lateral aspect of left leg [Figure - 1]. The lesion was asymptomatic. Tuberculosis verrucosa cutis was suspected initially because of its verrucous appearance, its presence over exposed area and the patient being of Asian subcontinent origin. But being in an area where cutaneous Leishmaniasis is endemic a slit- skin smear was taken from the edge of the lesion before a biopsy could be taken. Giemsa′s stain of the smear showed numerous Leishman Donovan bodies within the macrophages along with few lymphocytes, this clinched the diagnosis.

The patient was put on oral ketoconazole 400mg/day for eight weeks. By four weeks the lesion started flattening and two weeks after stopping the therapy complete resolution was seen [Figure - 2].

Discussion

The case is being discussed because of its uncommon morphological feature and its resemblance to cutaneous tuberculosis. The clinical diagnosis in this patient was suspected because of being in endemic zone, which was later confirmed by a slit- skin smear.

The different clinical types of cutaneous leishmaniasis represented different species affection, like the ulcerated wet type of rural lesions are produced by L. major, the dry urban type of lesions are produced by L. tropica and diffuse cutaneous leishmaniasis by L. aethiopica. In Leishmaniasis recidivans usually lupoid like lesions develop at the periphery of the scar of a healed lesion and rarely keloidal and verrucous forms have been described over the lower limbs.[2] A verrucous type of primary cutaneous leish maniasis lesion has not been commonly described earher.

Weinrauch et al reported that oral ketoconazole in doses of 200-400 mg/day yielded a 70% cure rate.[4] This patient was put on 400 mg of ketoconazole per day for eight weeks, by which time almost complete resolution was seen without any side effects of the drug.