IADVL
Indexed with PubMed and Science Citation Index (E) 
 
Users online: 3717 
     Home | Feedback | Login 
About Current Issue Archive Ahead of print Search Instructions Online Submission Subscribe What's New Contact  
  Navigate here 
  Search
 
  
 Resource links
   Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
   Article in PDF (1,475 KB)
   Citation Manager
   Access Statistics
   Reader Comments
   Email Alert *
   Add to My List *
* Registration required (free)  

 
  In this article
   References
   Article Figures

 Article Access Statistics
    Viewed3302    
    Printed31    
    Emailed0    
    PDF Downloaded169    
    Comments [Add]    
    Cited by others 1    

Recommend this journal

 


 
 Table of Contents    
NET LETTER
Year : 2012  |  Volume : 78  |  Issue : 2  |  Page : 229

An unusual case of multiple erythematous nodules with ulcerative lesion


Department of Dermatology, Venereology and Leprosy, Katihar Medical College and Hospital, Bihar, India

Date of Web Publication9-Mar-2012

Correspondence Address:
Abhijeet Kumar Jha
C/O-B.K. Jha (Anish), Advocate, Krishna Nagar, Mahavir Chowk, Saharsa, Bihar - 852 201
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0378-6323.93659

Rights and Permissions



How to cite this article:
Jha AK, Mallik SK, Ganguly S, Jaykar KC. An unusual case of multiple erythematous nodules with ulcerative lesion. Indian J Dermatol Venereol Leprol 2012;78:229

How to cite this URL:
Jha AK, Mallik SK, Ganguly S, Jaykar KC. An unusual case of multiple erythematous nodules with ulcerative lesion. Indian J Dermatol Venereol Leprol [serial online] 2012 [cited 2019 Aug 25];78:229. Available from: http://www.ijdvl.com/text.asp?2012/78/2/229/93659


Sir,

A 32-year-old female from eastern Bihar presented with multiple firm erythematous nodules distributed mainly over the extensor surfaces of the extremities [Figure 1]a and buttocks [Figure 2]a. These lesions started appearing 2 years ago and were steadily increasing both in size and in number. In addition, fungating, ulcerative and verrucous growths were observed on both the heels [Figure 3], which started 5 months ago. On examination, the peripheral nerves were normal, without hypopigmented patches or loss of sensation. There was no history of loss of weight. On asking specifically about the history of kala-azar, she revealed that she had suffered from the disease 4 years back and was improperly treated. Hematological and biochemical investigations were within normal limits. Slit-skin smear (SSS) for acid-fast bacilli was negative, but was positive for Leishman-Donovan (LD) bodies. The rK-39 test was positive and the histopathology was consistent with the diagnosis of Post Kala-Azar Dermal Leishmaniasis (PKDL). She was treated with IM sodium stibogluconate (20 mg/ kg/ day) for 4 weeks. The patient recovered completely and her skin lesions disappeared within a month [Figure 1]b and [Figure 2]b. A repeat SSS was negative for LD bodies. On histopathology, there was effacement of rete ridges, grenz zone and dense lymphohistiocytic infiltration [Figure 4]a along with multiple LD bodies [Figure 4]a and b.
Figure 1: (a) Erythematous nodules around the knees. (b) Complete resolution of knee lesions after 4 weeks

Click here to view
Figure 2: (a) Lesions on the buttocks. (b) Complete resolution of lesions on the buttocks

Click here to view
Figure 3: Verrucous growth on the heel

Click here to view
Figure 4: (a) Photomicrograph showing effacement of rete ridges, grenz zone and dense lymphohistiocytic infiltration. Multiple Leishman Donovan bodies are appreciable, marked with arrow (H and E, ×100). (b) Multiple Leishman Donovan bodies are appreciable, marked with circle (H and E, ×400)

Click here to view


Post kala-azar dermal leishmaniasis is a late cutaneous manifestation of leishmaniasis, first described by Brahmachari in 1922. [1] In India, the rash appears 1-2 years after recovery. [2] The early lesions are hypopigmented macules followed by diffuse nodulation. The rash is progressive over many years, and seldom heals spontaneously. The differential diagnoses of nodular lesions are leprosy, syphilis, onchocerciasis, mycosis fungoides, leukemia cutis and sarcoidosis. In PKDL, SSSs are usually positive. Histology shows a poorly differentiated infiltrate of chronic inflammatory cells, with a variable number of amastigotes in dermal macrophages.

Demonstration of LD bodies in the SSS or by culture of the skin tissue was considered to be the gold standard for the diagnosis of PKDL. [3] Recombinant DNA technology has produced serodiagnostic antigens, which include rK39, A2, ORF F, rH2A, rH2B, rGBP, rLACK and purified lipophospho-glycane (LPG). [4] We considered a differential diagnosis of histoid leprosy and mycosis fungoides for our case and ruled them out. Leishmaniasis recidivans was differentiated due to the absence of worsening of lesions during summers, and our patient was suffering from visceral leishmaniasis 2 years back without any cutaneous lesion during that period. We report this case because of the unusual features like complete absence of lesions on the face, as seen in PKDL, and ulcerative lesions on the heels. Therefore, a high index of suspicion has to be maintained in an endemic area, and PKDL should always be kept in the list of differential diagnoses.

 
  References Top

1.Brahmachari UN. A new form of cutaneous leishmaniasis - Dermal leishmanoid. Indian Med Gazette 1927;57:125-7.  Back to cited text no. 1
    
2.Klotz O, Lindenberg H. The pathology of leishmaniasis of the nose. Am J Trop Med 1922;3:117-41.  Back to cited text no. 2
    
3.Sharma MC, Gupta AK, Verma N, Das VN, Saran R, Kar SK. Demonstration of Leishmania parasites in skin lesions of Indian post kala-azar dermal leishmaniasis (PKDL) cases. J Commun Dis 2000;32:67-8.  Back to cited text no. 3
[PUBMED]    
4.Salotra P, Singh R. Challenges in the diagnosis of post kala-azar dermal leishmaniasis. Indian J Med Res 2006;123:295-310.  Back to cited text no. 4
[PUBMED]  Medknow Journal  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

This article has been cited by
1 Post Kala azar dermal leishmaniasis (PKDL) presenting with ulcerated chronic paronychia like lesion
Jha, A.K., Anand, V., Mallik, S.K., Kumar, P.
Kathmandu University Medical Journal. 2012; 10(40): 87-90
[Pubmed]



 

Top
Print this article  Email this article

    

Online since 15th March '04
Published by Wolters Kluwer - Medknow