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.