Erysipelas-like cutaneous leishmaniasis in a white man

Siah, TW; Charlton, F; Wahie, S; Lavender, T; Schwab, U

doi:10.1016/j.jaad.2012.12.488

Erysipelas-like cutaneous leishmaniasis in a white man

Lookup NU author(s): Dr Shyamal Wahie, Dr Ulrich Schwab

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Abstract

Cutaneous leishmaniasis (CL) is caused by intracellular protozoa of the genus Leishmania, transmitted by infected female sandflies. The incidence of CL is estimated to be 1.5 million new cases per year. CL has many different presentations, but the classical course of this disease is the appearance of small papules which progress to ulcerated plaques or nodules on exposed sites. We report a patient who demonstrated a rare and unusual presentation of CL mimicking periorbital cellulitis. A 61-year-old white man presented with a 3-month history of a slowly enlarging lesion on the right temple. It had become progressively painful and spread to involve the right eyelid. He had previously been on holiday in Ibiza 5 weeks before the onset of the problem. Clinical examination revealed an erythematous, edematous plaque with central crust and superficial ulceration on the right temple and prominent periorbital oedema affecting the right eye resembling erysipelas. He did not respond to treatment with flucloxacillin and topical steroid. Incisional biopsy from the lesion demonstrated a dense dermal mixed inflammatory cell infiltrate. In addition, there were numerous small round to oval basophilic organisms weakly stained with Giemsa stain found in histiocytes. Leishmania Donovani complex DNA was detected on skin biopsy PCR. Laboratory findings showed pancytopenia and abdominal ultrasound was normal. Subsequent bone marrow trephine could find no evidence of leishmaniasis. Blood leishmania IFAT and PCR were negative. The patient was diagnosed with CL and commenced on intravenous sodium stibogluconate (20 mg/kg) for 20 days. Treatment was complicated by a collapse caused by a prolonged QT interval secondary to hypokalemia (2.3 mmol/L) induced by sodium stibogluconate. He has since completed treatment and has residual mild periorbital edema. The erysipelas presentation of CL is rarely reported. The reason for this uncommon presentation is unclear though factor including an abhorrent host immune response has been postulated. This case highlights an unusual presentation of CL in a nonendemic country and the importance of taking a travel history in order to raise suspicion of this rare diagnosis in immunocompetent patients, as well as the potential complications of treatment. The associated pancytopenia with no evidence of bone marrow or visceral involvement is suggestive of an immune-mediated epiphenomenon.