Recurrent cutaneous leishmaniasis.

We present a case of an 18-year-old male patient who, after two years of inappropriate treatment for cutaneous leishmaniasis, began to show nodules arising at the edges of the former healing scar. He was immune competent and denied any trauma. The diagnosis of recurrent cutaneous leishmaniasis was made following positive culture of aspirate samples. The patient was treated with N-methylglucamine associated with pentoxifylline for 30 days. Similar cases require special attention mainly because of the challenges imposed by treatment.

Report

We present a case of an 18-year-old male patient from the northeast of Brazil. He had experienced an ulcer on the anterior face of his left thigh which was treated as American Cutaneous Leishmaniasis (ACL). The use of N-methylglucamine (7mgSbV/Kg/day) for 20 days ensured complete healing. However verrucous nodules began to appear at the periphery of the former atrophic scar two years after clinical cure (Figures 1 and 2). The patient presented no immunodeficiency.

FIGURE 1

Lesion with atrophic center permeated with hyperchromic areas and verrucous nodules on the borders

FIGURE 2

Detail of lesion formed by a central atrophic scar and verrucous nodules on the edges

A positive (6x5mm) Montenegro intradermoreaction was found, in addition to high titer (1:160) of anti-ACL antibodies showed by indirect immunofluorescence. The smear was negative, together with the cultures for mycobacteria and fungus. Histological examination showed pseudoepitheliomatous hyperplasia and linfohistioplasmocitoid granulomas (Figure 3).

FIGURE 3

Hematoxiciline and eosine stain - 40x: Histopathological examination with marked pseudoepitheliomatous hiperlasia and extensive dermal inflammatory infiltrate

The diagnosis of Recurrent Cutaneous Leishmaniasis (RCL) was confirmed after the positive culture of aspirate specimens using the McNeal, Novy & Nicolle culture medium.[1] The species L. (V.) braziliensis [ is endemic to the area of Brazil where the patient originated.

We decided to associate N-methylglucamine (20mgSbV/kg/day) with pentoxifylline (1200mg/day) for 30 days. [3,4] The patient achieved a long-term clinical cure, observed over a 3-year follow-up period.

RCL is rare, usually occurring within two years following the appearance of initial lesions. It is considered by many authors to be the result of inappropriate treatment.[5,6] Given the challenge of RCL we need to consider long-term follow-up of all cases which apparently have been wrongly treated.[3,4,7] Using an association of pentoxifylline in the treatment regime was effective probably due to its immunomodulatory function and its ability to regulate tumor necrosis factor-α levels.[8-10]