Disseminated cutaneous leishmaniasis in Old World mimicking histoid leprosy
A 25-year-old man presented to the outpatient clinic with an asymptomatic reddish plaque on the right forearm and multiple nodules on the face, scalp and neck for 3 months. The patient initially noticed an erythematous papule on the right forearm which had gradually increased in size to form a plaque followed by the appearance of multiple erythematous painless, nonitchy nodules on the face, scalp and neck. He was otherwise well with no systemic symptoms. He denied history of insect bite or contact with a leprosy-affected person. Cutaneous examination revealed an erythematous plaque measuring 1.0 × 0.5 cm on the right forearm with surface showing fine whitish scaling at the center. Multiple erythematous, shiny, dome-shaped and succulent nodules were seen scattered on the scalp, face and a few on the neck [Figure 1]. The nodules were present on normally appearing skin and were non-tender and firm in consistency. The differential diagnosis considered were histoid leprosy, cutaneous sarcoidosis and disseminated cutaneous leishmaniasis. Complete blood counts, liver and renal function tests, erythrocyte sedimentation rate, serum calcium and serum angiotensin-converting enzyme levels were normal and HIV serology was nonreactive. Slit skin smear for acid fast bacilli was negative while Giemsa-stained smear showed the presence of Leishman-Donovan bodies. Biopsies taken from the plaque on forearm and nodule on the face revealed numerous intracellular as well as extracellular leishmanial amastigotes, confirming the diagnosis of cutaneous leishmaniasis.
The classical clinical presentation of cutaneous leishmaniasis is described as a “volcano” ulcer and the disease is usually localised to the site of the sandfly bite but in some cases, it may get disseminated especially in immunocompromised patients. Disseminated cutaneous leishmaniasis is rarely reported from the Old World. The present case is an uncommon presentation of Old World cutaneous leishmaniasis in an immunocompetent patient.