An otherwise healthy 25-year-old Syrian man arrived in Canada as part of the country’s Syrian refugee program. The patient presented to our dermatology clinic with nonresolving indurated plaques on his forehead and left hand (Figures 1A and 1B). The plaques had been present for four weeks and were otherwise asymptomatic. For our differential diagnosis, we used the “Five L’s” for red dermal plaques on the face: lupus erythematosus/tumid lupus, Jessner lymphocytic infiltrate, lymphoma cutis, lymphocytoma cutis and polymorphous light eruption.1,2 Because of our patient’s country of origin, we also considered leprosy and leishmania. Great imitators, syphilis (lues) and sarcoid, can also be considered in this setting. A skin biopsy of the patient’s forehead plaque showed a dense lymphocytic and histiocytic infiltrate in the superficial and mid dermis. The histiocytes showed intracellular organisms with kinetoplasts, but no capsule on the Giemsa and hematoxylin and eosin stains (Figures 1C and 1D. Additional images are available in Appendix 1, at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.170844/-/DC1). Amastigotes were arranged radially around the periphery of the histiocyte. Polymerase chain reaction testing for leishmania identified the Leishmania tropica species of the parasite.
We referred our patient to the tropical disease clinic and after considering the cost versus benefit of intralesional sodium stibo-gluconate (not covered under the provincial drug benefit formulary), our patient chose treatment with three courses of cryotherapy,3 which led to a complete resolution of the lesions. Overall, when selecting a treatment, it is important to consider the specific strain of Leishmania and the extent of skin and systemic involvement.4,5 Pentavalent antimonial compounds, amphotericin B and other systemic treatments can be used in cases where extensive skin or systemic disease is confirmed.4,5
Footnotes
Competing interests: None declared.
This article has been peer reviewed.
The authors have obtained patient consent.