- Email: [email protected]
No walk in the park
The American Journal of Medicine (2005) 118, 715-716
IMAGES IN DERMATOLOGY
No walk in the park Diana D. Antonovich, MD,a Jeffrey P. Callen, MDb Parwathi Uma Paniker, MD, Images in Dermatology Editor a
Department of Dermatology, University of Colorado Health Sciences Center, Denver, Colo. Division of Dermatology, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
b
Presentation A 46-year-old man presented with an isolated ulcerated lesion on his forehead that had begun forming 4 months earlier (Figure 1). He reported that the lesion initially appeared to be an infected hair follicle. Five weeks prior to its onset, he had traveled to Belize, where he participated in excursions through the jungle. He denied any history of trauma or associated symptoms. An initial diagnosis of pyoderma was made, and the patient was treated with amoxicillin and mupirocin calcium cream, 2%. However, this treatment did not improve the lesion.
Assessment A subsequent biopsy revealed the presence of sarcoid granulomas (Figure 2). Tissue cultures were unremarkable. Treatment with intralesional triamcinolone injections and tacrolimus 0.1% ointment was prescribed, but this also proved unsuccessful. A repeat biopsy was performed, and this time, a dense granulomatous infiltrate was noted in the reticular dermis, along with macrophages containing numerous minute microorganisms (Figure 3). These were morphologically compatible with Leishmania.
Diagnosis Leishmaniasis is a protozoan disease transmitted to humans via the bite of a sand fly infected with Leishmania organRequests for reprints should be addressed to Parwathi “Uma” Paniker, MD. E-mail address: [email protected].
0002-9343/$ -see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.amjmed.2005.04.016
isms. This disease is categorized into New World leishmaniasis, endemic in South America and Central America, and Old World leishmaniasis, endemic in the Mediterranean, Middle East, Africa, Asia, and India. A rising incidence of leishmaniasis occurring in more developed countries has been attributed to increasing tourism and immigration and greater human susceptibility secondary to HIV infection. Several clinical variants exist: cutaneous, mucocutaneous, visceral, and diffuse cutaneous leishmaniasis. Cutaneous leishmaniasis is the result of direct intracellular infection of macrophages residing within the skin. Typical lesions begin weeks after inoculation as a painless papule on exposed skin. This later ulcerates. The differential diagnosis is vast and includes fungal infection, leprosy, malignancy, sarcoidosis, and tuberculosis. Histopathology is often non-specific, particularly in chronic lesions in which organisms tend to be sparse. Increased diagnostic sensitivity may be achieved by simultaneous use of more than one diagnostic technique, such as culture and histopathology. Additionally, the use of Leishmania-specific polymerase chain reaction has shown diagnostic promise.
Management The majority of cutaneous infections will spontaneously resolve with time, however, systemic treatment is recommended for individuals with New World leishmaniasis. Left untreated, these people are at increased risk of progression to potentially mutilating mucocutaneous disease, even years after clinical resolution of cutaneous disease. Systemic therapies include treatment with azole antifungals, intravenous (IV) pentamidine, amphoteracin B, and IV pentavalent antimony (ie, sodium stibogluconate; the drug is only avail-
716
The American Journal of Medicine, Vol 118, No 7, July 2005
Figure 1 The patient had this crusted ulceration on the forehead for 4 months. Figure 3 The arrow denotes the organisms that have invaded macrophages.
able through the Centers for Disease Control). This case emphasizes the diagnostic challenge of leishmaniasis and the need for greater awareness among clinicians in nonendemic areas. This patient was treated with fluconazole, 200 mg by mouth each day. After a 6-week course of therapy, there was complete resolution of the lesion. At a 4-month follow-up visit, the patient remained well without evidence of recurrence.
Figure 2
A biopsy revealed a dense granulomatous infiltrate.
IMAGES IN DERMATOLOGY
No walk in the park Diana D. Antonovich, MD,a Jeffrey P. Callen, MDb Parwathi Uma Paniker, MD, Images in Dermatology Editor a
Department of Dermatology, University of Colorado Health Sciences Center, Denver, Colo. Division of Dermatology, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
b
Presentation A 46-year-old man presented with an isolated ulcerated lesion on his forehead that had begun forming 4 months earlier (Figure 1). He reported that the lesion initially appeared to be an infected hair follicle. Five weeks prior to its onset, he had traveled to Belize, where he participated in excursions through the jungle. He denied any history of trauma or associated symptoms. An initial diagnosis of pyoderma was made, and the patient was treated with amoxicillin and mupirocin calcium cream, 2%. However, this treatment did not improve the lesion.
Assessment A subsequent biopsy revealed the presence of sarcoid granulomas (Figure 2). Tissue cultures were unremarkable. Treatment with intralesional triamcinolone injections and tacrolimus 0.1% ointment was prescribed, but this also proved unsuccessful. A repeat biopsy was performed, and this time, a dense granulomatous infiltrate was noted in the reticular dermis, along with macrophages containing numerous minute microorganisms (Figure 3). These were morphologically compatible with Leishmania.
Diagnosis Leishmaniasis is a protozoan disease transmitted to humans via the bite of a sand fly infected with Leishmania organRequests for reprints should be addressed to Parwathi “Uma” Paniker, MD. E-mail address: [email protected].
0002-9343/$ -see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.amjmed.2005.04.016
isms. This disease is categorized into New World leishmaniasis, endemic in South America and Central America, and Old World leishmaniasis, endemic in the Mediterranean, Middle East, Africa, Asia, and India. A rising incidence of leishmaniasis occurring in more developed countries has been attributed to increasing tourism and immigration and greater human susceptibility secondary to HIV infection. Several clinical variants exist: cutaneous, mucocutaneous, visceral, and diffuse cutaneous leishmaniasis. Cutaneous leishmaniasis is the result of direct intracellular infection of macrophages residing within the skin. Typical lesions begin weeks after inoculation as a painless papule on exposed skin. This later ulcerates. The differential diagnosis is vast and includes fungal infection, leprosy, malignancy, sarcoidosis, and tuberculosis. Histopathology is often non-specific, particularly in chronic lesions in which organisms tend to be sparse. Increased diagnostic sensitivity may be achieved by simultaneous use of more than one diagnostic technique, such as culture and histopathology. Additionally, the use of Leishmania-specific polymerase chain reaction has shown diagnostic promise.
Management The majority of cutaneous infections will spontaneously resolve with time, however, systemic treatment is recommended for individuals with New World leishmaniasis. Left untreated, these people are at increased risk of progression to potentially mutilating mucocutaneous disease, even years after clinical resolution of cutaneous disease. Systemic therapies include treatment with azole antifungals, intravenous (IV) pentamidine, amphoteracin B, and IV pentavalent antimony (ie, sodium stibogluconate; the drug is only avail-
716
The American Journal of Medicine, Vol 118, No 7, July 2005
Figure 1 The patient had this crusted ulceration on the forehead for 4 months. Figure 3 The arrow denotes the organisms that have invaded macrophages.
able through the Centers for Disease Control). This case emphasizes the diagnostic challenge of leishmaniasis and the need for greater awareness among clinicians in nonendemic areas. This patient was treated with fluconazole, 200 mg by mouth each day. After a 6-week course of therapy, there was complete resolution of the lesion. At a 4-month follow-up visit, the patient remained well without evidence of recurrence.
Figure 2
A biopsy revealed a dense granulomatous infiltrate.