Advertisement

Granulomatous lesions of the skin: Do not fall into the trap

Published:March 21, 2022DOI:https://doi.org/10.1016/j.ejim.2022.03.020

      Keywords

      1. Case

      A 51-year-old woman was referred to investigate skin lesions present on her backside.
      She had no past medical history and was not taking medication. She travelled several times to China (last time in 2009) and Brazil (2015).
      She complained of purple papules on her backside since 6 months (Fig. 1A-B). A biopsy made in another hospital, three months earlier, showed non-necrotizing granulomatous lesions (Fig. 1C). Besides the cutaneous lesions, our patient had no other symptoms and her clinical exam was strictly normal. Lab results were also strictly normal. She was referred to our hospital for a suspicion of cutaneous sarcoidosis. The lesions did not change of aspect the past several months, were unpainful and not itchy.
      Fig 1
      Fig. 1Clinical (A-B) and histopathological (C) aspect of skin lesions.
      What is the diagnosis?

      2. Diagnosis

      A 18F FDG PET/CT was normal and allowed us to exclude systemic sarcoidosis. Histology revealed two non-necrotizing granulomatous dermatitis of the papillary dermis (Fig. 1-C). PCR Leishmania made on the skin biopsy was positive for Leishmania Infantum and the diagnosis of cutaneous Leishmaniasis was retained.

      3. Discussion

      In our European regions, non-necrotizing granulomatous lesions of the skin are usually due to sarcoidosis. However, Leishmaniasis should be suspected in cases with history of traveling to endemic regions of Leishmaniasis.
      Leishmaniasis is a poverty-related disease with two clinical forms: visceral leishmaniasis (VL) and cutaneous leishmaniasis (CL). 0·7–1 million new cases per year are reported from 100 endemic countries [
      • Burza S.
      • Croft S.L.
      • Leishmaniasis Boelaert M.
      ].
      L. Infantum can give visceral and cutaneous disease. Typically, L. Infantum causes a small number of slow-growing nodular lesions that can persist for years with minimal inflammation as in our case. It often appears in children under the age of 5 years old or in immunocompromised patients, in China, Brazil, South and Central America and Southern Europe [
      • Burza S.
      • Croft S.L.
      • Leishmaniasis Boelaert M.
      ].
      The diagnosis is classically through microscopic observation of the amastigote parasite stage, known as Leishman-Donovan (LD) bodies, in tissues. However, histopathological analysis may fail to detect amastigotes, especially when granulomas predominate [
      • Wijesinghe H.
      • Gunathilaka N.
      • Semege S.
      • Pathirana N.
      • Manamperi N.
      • de Silva C.
      • Fernando D.
      Histopathology of Cutaneous Leishmaniasis Caused by Leishmania donovani in Sri Lanka.
      ]. Even after relecture, these bodies were not found in our patient. Serological essays are also available but polymerase chain reaction (PCR) assay is the most sensitive test used for the diagnosis [
      • Aronson N.
      • Herwaldt B.L.
      • Libman M.
      • Pearson R.
      • Lopez-Velez R.
      • Weina P.
      • et al.
      Diagnosis and Treatment of Leishmaniasis: clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH).
      ].
      Treatment of CL depends on multiple factors (number of lesions, size, risk of mucosal involvement, no spontaneous healing, risk of poor cosmetic outcome or visceral damage) [
      • Aronson N.
      • Herwaldt B.L.
      • Libman M.
      • Pearson R.
      • Lopez-Velez R.
      • Weina P.
      • et al.
      Diagnosis and Treatment of Leishmaniasis: clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH).
      ]. Since the lesions of our patient did not heal spontaneously but were of small size, she was treated by cryotherapy.

      Conflicts of interests and funding

      None.

      Informed consent

      Patient consent has been obtained.

      References

        • Burza S.
        • Croft S.L.
        • Leishmaniasis Boelaert M.
        Lancet. 2018; 392: 951-970
        • Wijesinghe H.
        • Gunathilaka N.
        • Semege S.
        • Pathirana N.
        • Manamperi N.
        • de Silva C.
        • Fernando D.
        Histopathology of Cutaneous Leishmaniasis Caused by Leishmania donovani in Sri Lanka.
        Biomed Res Int. 2020; 20204926819
        • Aronson N.
        • Herwaldt B.L.
        • Libman M.
        • Pearson R.
        • Lopez-Velez R.
        • Weina P.
        • et al.
        Diagnosis and Treatment of Leishmaniasis: clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH).
        Clin Infect Dis. 2016; 63: e202-e264