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Disseminated cutaneous leishmaniasis: ulcerovegetative and ulcero-crusted lesions
ARTICLE IN PRESS
BJID 685 1–2
braz j infect dis 2 0 1 6;x x x(x x):xxx–xxx
The Brazilian Journal of
INFECTIOUS DISEASES www.elsevier.com/locate/bjid
Clinical image
1
Disseminated cutaneous leishmaniasis: ulcerovegetative and ulcero-crusted lesions
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Isabela Martins Sgarbi a , Flávia da Silva Domingos Santos a , Veridiana Elisa Monteiro a , Silvia Nunes Szente Fonseca b , Fred Bernardes Filho a,∗
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a
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b
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Q1
Hospital São Francisco, Departamento de Medicina Interna, Ribeirão Preto, SP, Brazil Hospital São Francisco, Departamento de Doenc¸as Infecciosas e de Controle de Infec¸ões, Ribeirão Preto, SP, Brazil
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a r t i c l e
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Article history:
12
Received 7 October 2016
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Accepted 26 October 2016
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Available online xxx
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A 69-year-old male patient, with history of multiple furuncles for two months, without improvement after the use of cephalexin and amoxicillin/clavulanate for 20 days, and daily fever for a week. On dermatological examination, multiple ulcerovegetative and ulcero-crusted cutaneous lesions on the face, ears, scalp, back, upper and lower limbs and genitalia were observed (Figs. 1 and 2). There was no lymphadenopathy. Based on the clinical picture the hypotheses of disseminated cutaneous leishmaniasis, paracoccidioidomycosis, and malignant syphilis were raised. Laboratory tests (blood count, renal function, hepatography, and coagulogram) were normal. Serology for hepatitis, syphilis, HIV, and Leishmania donovani were negative. Swabs taken from open lesions for direct mycological examination and culture for fungi were negative. Histopathological of the edge of an ulcer on the dorsum demonstrated dense lymphohistiocytic inflammatory infiltrate with plasma and mast cells, in addition to neutrophils and granuloma formation; hyperplastic skin surrounded with
areas of pseudoepitheliomatous pattern. Giemsa and ZiehlNeelsen staining were negative for fungi and acid-fast bacilli, respectively. Rounded and oval structures with kinetoplast, phagocytosed in macrophages were observed. Based on clinical and histological picture of chronic ulcerated dermatitis associated with leishmanias, the diagnosis of disseminated cutaneous leishmaniasis was established, the treatment with meglumine antimoniate 20 mg/kg/day was started, and administered for 30 days. After 20 days of the end of treatment, there was healing of skin and mucosal lesions. He is in the ninth month of followup, with no appearance of new lesions and complications (Fig. 3). A negative serology for L. donovani came as no surprise, as this agent causes visceral leishmaniasis, with rare cases of skin lesions described in the literature.1,2 Currently considered an emerging form of the disease,3 disseminated leishmaniasis should be detected early, recognizing its clinical spectrum and disabling potential.
∗
Corresponding author. E-mail address: f9fi[email protected] (F.B. Filho). http://dx.doi.org/10.1016/j.bjid.2016.10.014 1413-8670/© 2016 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Infectologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Sgarbi IM, et al. Disseminated cutaneous leishmaniasis: ulcerovegetative and ulcero-crusted lesions. Braz J BJID 685 1–2 Infect Dis. 2016. http://dx.doi.org/10.1016/j.bjid.2016.10.014
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BJID 685 1–2
2
ARTICLE IN PRESS b r a z j i n f e c t d i s . 2 0 1 6;x x x(x x):xxx–xxx
Fig. 1 – Multiple cutaneous ulcerovegetative and ulcero-crusted reddish lesions were observed on the ears, face, and scalp. Superficial involvement of mucosae was recognized on the nose.
Fig. 2 – Papules, nodules, infiltrated erythemas were found on the dorsum. Induration of the lesions was palpable.
Fig. 3 – Clinical cure after the treatment. (A) Absence of skin and mucosal lesions; (B) hypochromic-atrophic scars on the dorsum.
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Conflicts of interest The authors declare no conflicts of interest.
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references 53
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1. Bernardes Filho F, Bonatto DC, Martins G, Maier LM, Nery JAC, Azulay-Abulafia L. Occurrence of two autochthonous cases of American cutaneous leishmaniasis in the neighborhood of
Caju, city of Rio de Janeiro, Brazil. An Bras Dermatol. 2014;89:848–50. 2. Gelanew T, Hurissa Z, Diro E, et al. Disseminated cutaneous leishmaniasis resembling post-kala-azar dermal leishmaniasis caused by Leishmania donovani in three patients co-infected with visceral leishmaniasis and human immunodeficiency virus/acquired immunodeficiency syndrome in Ethiopia. Am J Trop Med Hyg. 2011;84:906–12. 3. Vernal S, De Paula NA, Gomes CM, Roselino AM. Disseminated leishmaniasis by Leishmania viannia subgenus: a series of 18 cases in southeastern Brazil. Open Forum Infect Dis. 2016;3:ofv184.
Please cite this article in press as: Sgarbi IM, et al. Disseminated cutaneous leishmaniasis: ulcerovegetative and ulcero-crusted lesions. Braz J BJID 685 1–2 Infect Dis. 2016. http://dx.doi.org/10.1016/j.bjid.2016.10.014
56 57 58 59 60 61 62 63 64 65 66 67
BJID 685 1–2
braz j infect dis 2 0 1 6;x x x(x x):xxx–xxx
The Brazilian Journal of
INFECTIOUS DISEASES www.elsevier.com/locate/bjid
Clinical image
1
Disseminated cutaneous leishmaniasis: ulcerovegetative and ulcero-crusted lesions
2
3
5
Isabela Martins Sgarbi a , Flávia da Silva Domingos Santos a , Veridiana Elisa Monteiro a , Silvia Nunes Szente Fonseca b , Fred Bernardes Filho a,∗
6
a
7
b
4
Q1
Hospital São Francisco, Departamento de Medicina Interna, Ribeirão Preto, SP, Brazil Hospital São Francisco, Departamento de Doenc¸as Infecciosas e de Controle de Infec¸ões, Ribeirão Preto, SP, Brazil
8
9
a r t i c l e
i n f o
10 11
Article history:
12
Received 7 October 2016
13
Accepted 26 October 2016
14
Available online xxx
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
A 69-year-old male patient, with history of multiple furuncles for two months, without improvement after the use of cephalexin and amoxicillin/clavulanate for 20 days, and daily fever for a week. On dermatological examination, multiple ulcerovegetative and ulcero-crusted cutaneous lesions on the face, ears, scalp, back, upper and lower limbs and genitalia were observed (Figs. 1 and 2). There was no lymphadenopathy. Based on the clinical picture the hypotheses of disseminated cutaneous leishmaniasis, paracoccidioidomycosis, and malignant syphilis were raised. Laboratory tests (blood count, renal function, hepatography, and coagulogram) were normal. Serology for hepatitis, syphilis, HIV, and Leishmania donovani were negative. Swabs taken from open lesions for direct mycological examination and culture for fungi were negative. Histopathological of the edge of an ulcer on the dorsum demonstrated dense lymphohistiocytic inflammatory infiltrate with plasma and mast cells, in addition to neutrophils and granuloma formation; hyperplastic skin surrounded with
areas of pseudoepitheliomatous pattern. Giemsa and ZiehlNeelsen staining were negative for fungi and acid-fast bacilli, respectively. Rounded and oval structures with kinetoplast, phagocytosed in macrophages were observed. Based on clinical and histological picture of chronic ulcerated dermatitis associated with leishmanias, the diagnosis of disseminated cutaneous leishmaniasis was established, the treatment with meglumine antimoniate 20 mg/kg/day was started, and administered for 30 days. After 20 days of the end of treatment, there was healing of skin and mucosal lesions. He is in the ninth month of followup, with no appearance of new lesions and complications (Fig. 3). A negative serology for L. donovani came as no surprise, as this agent causes visceral leishmaniasis, with rare cases of skin lesions described in the literature.1,2 Currently considered an emerging form of the disease,3 disseminated leishmaniasis should be detected early, recognizing its clinical spectrum and disabling potential.
∗
Corresponding author. E-mail address: f9fi[email protected] (F.B. Filho). http://dx.doi.org/10.1016/j.bjid.2016.10.014 1413-8670/© 2016 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Infectologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Sgarbi IM, et al. Disseminated cutaneous leishmaniasis: ulcerovegetative and ulcero-crusted lesions. Braz J BJID 685 1–2 Infect Dis. 2016. http://dx.doi.org/10.1016/j.bjid.2016.10.014
33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
BJID 685 1–2
2
ARTICLE IN PRESS b r a z j i n f e c t d i s . 2 0 1 6;x x x(x x):xxx–xxx
Fig. 1 – Multiple cutaneous ulcerovegetative and ulcero-crusted reddish lesions were observed on the ears, face, and scalp. Superficial involvement of mucosae was recognized on the nose.
Fig. 2 – Papules, nodules, infiltrated erythemas were found on the dorsum. Induration of the lesions was palpable.
Fig. 3 – Clinical cure after the treatment. (A) Absence of skin and mucosal lesions; (B) hypochromic-atrophic scars on the dorsum.
Q2
51
Conflicts of interest The authors declare no conflicts of interest.
52
references 53
54 55
1. Bernardes Filho F, Bonatto DC, Martins G, Maier LM, Nery JAC, Azulay-Abulafia L. Occurrence of two autochthonous cases of American cutaneous leishmaniasis in the neighborhood of
Caju, city of Rio de Janeiro, Brazil. An Bras Dermatol. 2014;89:848–50. 2. Gelanew T, Hurissa Z, Diro E, et al. Disseminated cutaneous leishmaniasis resembling post-kala-azar dermal leishmaniasis caused by Leishmania donovani in three patients co-infected with visceral leishmaniasis and human immunodeficiency virus/acquired immunodeficiency syndrome in Ethiopia. Am J Trop Med Hyg. 2011;84:906–12. 3. Vernal S, De Paula NA, Gomes CM, Roselino AM. Disseminated leishmaniasis by Leishmania viannia subgenus: a series of 18 cases in southeastern Brazil. Open Forum Infect Dis. 2016;3:ofv184.
Please cite this article in press as: Sgarbi IM, et al. Disseminated cutaneous leishmaniasis: ulcerovegetative and ulcero-crusted lesions. Braz J BJID 685 1–2 Infect Dis. 2016. http://dx.doi.org/10.1016/j.bjid.2016.10.014
56 57 58 59 60 61 62 63 64 65 66 67