Results
Written informed consent to enroll the study and use clinical images in case report was obtained from the patient.
Granuloma structures characterized by epithelioid histiocytes in the dermis were observed in the prepared sections. Langerhans-type multinucleate giant cells were noteworthy which were found in granulomas suggestive of leishmaniasis, tuberculosis with Hematoxylin-eosin staining (200X) (Figure 1). Intense mononuclear inflammatory cells surrounding the granuloma infiltrate the granuloma were also noteworthy. Granulomas were mostly observed in the dermis. The histomorphological findings seemed to be compatible with lupus vulgaris. However, a definitive differential diagnosis could not be performed.
No bacteria was observed with Gram staining, no Mycobacteria was observed with EZN staining and no fungal organism was observed with PAS staining.
A few amastigotes of Leishmania were observed with Giemsa staining. Detection of Leishmania amastigotes by the microscopic examination of the direct smears exudative fluid of the lesions strictly supported the definitive differrantial diagnosis of lupoid CL. It has been reported that Leishmania amastigotes are usually absent on microscopy, thus, PCR is especially recommended for diagnosis of CL to prevent the delayed diagnosis or clinical and histological misdiagnosis often with Lupus vulgaris3. In light of this data, Real Time PCR was used to identify the Leishmaniaspecies, which was found to be L. major (Figure 2).
Figure 1.   Non-caseified granulomas including giant cells (green arrow) and Leishmaniaamastigotes (red arrow) were seen in dermis (Hematoxylin-eosin, X200)
Figure 2. Real-time PCR analysis of Leishmania  major infection in lesion of the patient
Identification of polymerase chain reaction products with melting temperature analysis of two L. major samples and two samples ofLeishmania major belonged to the patient. The melting temperature is 850 C for L. major MHOM/SR/2015/HRURFA012.
The patient with lupoid CL (Figure 3) was treated with intralesional meglumine antimoniate (Glucantime®) injections twice a week (Monday-Thursday) for four weeks. After four weeks, the patient was called monthly for control the healing of the lesion for one year, it was seen that the lesion was regressed (Figure 4).
The plaque type occurred over the finger and presented clinically as well-defined erythematous plaques that sometimes extended to involve the whole finger resembling lupus vulgaris.
Figure 3. Lesion of the lupoid CL before treatment
Figure 4. Lupoid CL, after treatment of the lesion with intralesional meglumine antimoniate (Glucantime®)