Discussion
Leishmaniasis is a neglected vector-borne disease caused by protozoan parasites belonging
to Leishmania genus, and endemic in all WHO regions, including Turkey. There are 4 main clinical classifications of the leishmaniasis, visceral, post-kala-azar dermal, cutaneous (CL) and mucocutaneous. Turkey is considered to have a high burden country for CL4. Although a National control programme has been established, CL is still a serious public health problem with increasing the number of CL cases due to the Syrian conflict in Turkey, particularly in Southeastern and Southern regions of the country. Sanliurfa is a hyper-endemic province of CL in Southeastern region of Turkey. Various clinical presentations of CL including papule, nodule, ulcerative, noduloulcerative, and recidivans forms have been reported in Sanliurfa5-8. Noduloulcerative form, classically known as oriental sore, is the most common form in study area.
To the best of our knowledge, lupoid CL mimicking lupus vulgaris has not been reported from Sanliurfa, Southeastern Region of Turkey. However, a few lupoid CL cases have been reported in different provinces of Turkey9; 10. Of all CL cases the incidence of Leishmaniasis recidivans has been reported with 0,5%-6,2% in the Middle East and Afghanistan11. In a recent study carried out in Tunisia, lupoid CL represented 9% of cases in adults12. It has been reported that in lupoid CL, theLeishmania amastigotes are usually absent or rare on a microbiological smear 13-15. The paucity ofLeishmania amastigotes in the lesion samples and in direct smears might lead to misdiagnosis with lupus vulgaris11; 13-15. Since, it has been reported that clinically and histologically, lupoid leishmaniasis is similar to lupus vulgaris, which is considered as the most important differential diagnosis16; 17. Contrary to other studies13-15, we detected fortunately Leishmania amastigotes in direct smears of the lesion of the patient. This can be explained by the short duration of the patient’s lesions (approximately 3-5 months) at the moment of diagnosis. We detected also Leishmania DNA by ITS 1 PCR and identified by Real time PCR. We found that L. major is responsible agent for this LCL case, which is compatible with the other studies14; 18; 19. Leishmania tropica is considered to be the most common, and L. major is the rare causative agent of lupoid CL11; 14; 15; 20. In a study it has been reported species-specific PCR analysis is sensitive in cases of acute cutaneous leishmaniasis, but in lupoid leishmaniasis it is less sensitive14.
There is no standardized treatment for this condition and thus multiple treatments have been reported with varying degrees of success. Treatment options include cryotherapy, topical antimonial compounds and intralesional pentavalent antimony. This patient was treated with intralesional meglumine antimoniate (Glucantime®) injections twice a week for four weeks with marked improvement of clinical features.