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.