Correspondence Address:
Bushra Moiz
Department of Pathology & Microbiology, The Aga Khan University, Karachi
Pakistan

Full Text

Sir,

A 35-year-old soldier presented with ulcerated nodule on the nape of his neck. He had recently returned after a month's stay at Baluchistan. His past medical history was nil relevant, physical examination was insignificant except for the presence of ulcerated skin lesion on the back of his neck in the inter-scapular region [Figure 1]. The ulcer crater was 1.5 inches in its long axis and had raised and inflamed margins. He was afebrile and there was no lymphadenopathy or visceromegaly. The material was aspirated from ulcer and subsequent smear was stained with Leishman stain which showed a single histiocyte loaded with amastigote forms of Leishmania tropica [Figure 2].

After a diagnosis of cutaneous leishmaniasis, the patient was offered parenteral stibogluconate for 20 days. His response to treatment was dramatic with resolution of his skin ulcer within four weeks.

Localized cutaneous leishmaniasis is characterized clinically by the appearance of inflammatory painless papule on exposed skin which, therefore, is commonly seen on face. It represents the site of sand fly bite and is caused by a protozoon Leishmania tropica. The papule increases in size and progresses to become a nodule over a period of two to eight weeks which may ulcerate. There may be multiple satellite lesions. The sore is typically large and painless but may be painful in case of secondary bacterial infections. [1]

Complete blood count may be normal or may show mild anemia with leucopenia and thrombocytopenia. The dermal scraping, imprint from punch skin biopsy and needle aspiration are useful in demonstrating parasites in smears stained with Leishman or Giemsa. The parasites are seen as round amastigotes phagocytosed in histiocytes as seen in our patient also. Amastigote is identified by its nucleus and rod shaped kinetoplast. The latter is a mitochondrial structure containing DNA. The protozoa may, however, be absent in old or healed ulcers.

Some common skin ulcers that may be mistaken for cutaneous leishmaniasis include cutaneous anthrax, cutaneous tuberculosis, erythema nodosum, erythema nodosum leprosum and sarcoidosis.

Proper management of cutaneous leishmaniasis is very important as though it is usually a mild disease and lesions heal spontaneously most of the times, but they often leave ugly scars. Treatment is usually advisable because of cosmetic reasons and patient's low immunity due to which lesions can recur. [2] For years the drugs of choice for all types of leishmaniasis were antimonial compounds. Cutaneous leishmaniasis can be treated with antimonial drugs like meglumine antimoniate or sodium stibogluconate. Emergence of resistance to the conventional antimonials led to the use of parenteral amphotericin C for a period of eight weeks. Other drugs that can be used include pentamdine isethionate, topical paramomycin and allopurinol. [3]

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