Discussion
Immunosuppressive treatments alter clinical manifestations of CL and it has been shown in previous studies that immunocompromised patients experience more severe symptoms compared to the immunocompetent. (5) Unconventional manifestations of this disease can cause a delay in diagnosis resulting in harsh circumstances such as scarring, defacement and even disablement. (6) The current case mimicked different conditions. The initial lesions were scaly and erythematous papules and plaques that covered both upper limbs, torso and distal of lower limbs which resembled psoriasis. Plaques in some areas were ulcerated with serous discharge mimicking mycobacterial infection. Some of the lesions were edematous and inflammated which alongside the poor general condition of the patient and fever resembled sweet syndrome. The oral ulcers made the primary health care practitioner think of herpetic infection due to immunosuppression. The association of histopathology with PCR led to diagnosis.
In this case presentation we report a recurrent and disseminated CL with a very rare and unusual clinical presentation. Disseminated Cutaneous Leishmaniasis is a rare manifestation of CL and is linked to the cellular immunity. (4) To the best of our knowledge there have been three reports of disseminated CL after treatment with immunosuppressive drugs following organ transplants. (7,8,9) Two cases of disseminated leishmaniasis by Leishmania.tropica were reported in patients with HIV in Iran which presented with multiple skin lesions on face and extremities. (10) Also Alcover et al reported a case of diffuse CL byLeishmania.infantum in a Patient with psoriasis and RA undergoing anti-TNF therapy. (11)
There have been some reports on reactivation of CL infection in patients receiving immunosuppressive treatments for RA, the first case of CL reactivation was witnessed in a RA patient under treatment with systemic corticosteroids in 2005 but it was caused by Leishmania.donovani  and presented with a single ulcerated lesion. (12) Another report of Visceral and Mucocutaneous Leishmaniasis recurrence was in a Belgian woman with a long history of severe RA who had been treated with etanercept, ciclosporin and methylprednisolone. (13) The current case correlates with earlier reports that CL can cause unconventional clinical manifestation and reactivation in patients receiving immunosuppressive treatments, however the appearance and extent of our patient’s lesions were different from any reports that’s been done. Also unlike other similar studies the patient was solely being treated with prednisolone.
The standard treatment for disseminated leishmaniasis is systemic antimonial compounds (14, 15), which in this case the aforementioned treatment course was completed and clinical improvement was witnessed.