Complicated Mucocutaneous Leishmaniasis With Superimposed Cellulitis in an Immunocompromised Patient: A Case Report

Abstract

Leishmaniasis is a common protozoal infection that could be cutaneous (CL), mucocutaneous (MCL), or visceral. CL, which is the most common form, is typically localized. Therefore, it becomes more difficult to diagnose it when presenting with diffuse lesions. In this case, a 54-year-old man presented with skin lesions involving his trunk, extremities, and face, including the nasal mucosa. His past medical history was remarkable for MCL with synovial leishmaniasis, systemic lupus erythematosus (SLE), and non-Hodgkin's lymphoma (NHL). Skin biopsies showed intracytoplasmic leishmania amastigotes; polymerase chain reaction (PCR) was positive for leishmania DNA; and a culture from purulent skin lesions grew Pseudomonas aeruginosa. So, MCL with superimposed cellulitis was diagnosed, and the patient was treated with intravenous liposomal amphotericin B and ceftazidime. Leishmaniasis is an infection that has accurate diagnostic tests and various treatment options. However, the difficulty is in being able to suspect it clinically, as it can mimic a wide range of diseases with cutaneous involvement. Therefore, visual awareness of the spectrum of disease presentations is arguably the most challenging and important skill to acquire in the diagnosis and management of CL. This case represents a rare form of MCL.

Keywords: cellulitis; immunocompromised; leishmania amastigotes; mucocutaneous leishmaniasis; synovial leishmaniasis.

Figure 1. Erythematous nodular skin lesions that are ulcerated and crusted over the trunk (A), extremities (B), and left ankle (C).

Figure 2. The extensor surface of the right forearm and dorsum of the right hand.

A: at presentation, the lesions in this area were purulent; B, C: show the same area two weeks and two months later, respectively. In Figure 2B, the lesions started to re-epithelize. In Figure 2C, they became dry and scaly.

Figure 3. Microscopic images of the skin biopsy.

A: skin biopsy of a lesion showing a necrotizing granuloma (original magnification x40, hematoxylin and eosin staining); B: A x400 magnification showing the intracytoplasmic leishmania amastigotes (red circles).