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®)