Leishmaniasis recidivans in a nonendemic area that responded to doxycycline

S Pragna¹, R Sivayogana¹, R Sudha¹, S Vindu²,  
¹ Department of Dermatology, Venereology and Leprosy, Sri RamachandraInstitue of Higher Education and Research, Chennai, Tamil Nadu, India
² Pathology, Sri Balaji Medical College and Hospital, Chennai, Tamil Nadu, India

Correspondence Address:
R Sivayogana
Department of Dermatology, Venereology and Leprosy, Sri RamachandraInstitue of Higher Education and Research, Chennai, Tamil Nadu
India

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We report a 53-year-old, male factory worker who presented with complaints of painful swelling and ulcers over the left leg for a duration of 20 days. He was initially treated as a case of cellulitis with injection amoxicillin, which failed to show any clinical improvement. The patient also gave history of two such episodes in the same leg in the past 2 years. He claimed that the previous lesions had healed upon treatment, details of which were not known. There was no history of discharge from the painful swellings and ulcers. On examination, the left leg was edematous with diffuse hyperpigmentation of the lower two-thirds of the leg. Multiple erythematous nodules with central erosions were seen circumferentially [Figure 1]. No active discharge was appreciated. Potassium hydroxide mount was negative for hyphae or spores and Gram stain from the nodule showed pus cells. Clinically, patient was suspected to have cutaneous tuberculosis, botryomycosis, subcutaneous mycosis, vasculitis, and biopsy was done. He was treated symptomatically with doxycycline 100 mg bd and analgesics for 1 week. Histopathological examination revealed hyperplastic epidermis, and dermis showed mixed infiltrates of plasma cells, lymphocytes, and many histiocytes containing amastigotes of Leishmania organisms [Figure 2], which was confirmed with Giemsa stain. On follow-up, lesions over the left leg showed near complete improvement. On further probing, patient revealed history of travel to Uttar Pradesh (northern Indian state) every year. Based on histopathology and recurrent nature of lesion, diagnosis of leishmaniasis recidivans was confirmed.{Figure 1}{Figure 2}

Efforts were made to acquire miltefosine or antimonials, but they were not available in our area. Due to the cost factor, we were unable to give injection amphotericin. As the lesion was improving with doxycycline, patient was asked to continue tablet doxycycline 200 mg/day for 1 month. After one month, lesions healed completely with post inflammatory hyperpigmentation and atrophic scarring. The patient is on regular follow-up for the last 6 months.

Leishmaniasis is a vector-borne parasitic disease transmitted by sandflies. Cutaneous Ieishmaniasis is showing resurgence in recent times even in nonendemic regions of India. Major human diseases in leishmaniasis include localized cutaneous, diffuse cutaneous, mucocutaneous, and visceral type. Localized cutaneous leishmaniasis (LCL) is the most common among these. All leishmaniasis species can cause a localized disease with varying clinical presentations. Acute LCL heals spontaneously within a year and lesions lasting more than a year are called chronic LCL.[1] Leishmaniasis recidivans is one of the rare forms of chronic LCL. Failure of cell-mediated immunity to clear the organism despite exaggerated hypersentivity is the reason for recurrence of lesion in same site.[2] This may be due to incomplete treatment, reactivation of dormant organisms (after trauma or usage of topical steroids, etc.), or reinfection. This type is supposed to have higher morbidity, more duration to recover, and more resistance to the standard treatment regimens. Apart from ulcers, leishmaniasis recidivans can present as brown-red papules (lupus vulgaris like), keloidal plaques, verrucous lesions, and psoriasiform lesions.[2] Though cutaneous leishmaniasis is rarely encountered in our state, history of travel to endemic area, histopathological examination, and special stains helped in confirming the diagnosis and to rule out differentials such as subcutaneous mycoses, cutaneous tuberculosis, atypical mycobacterial infection, botryomycosis, and vasculitic ulcers. Doxycycline, though not the first choice of medication, is considered equally efficacious to pentavalent antimony. It has good intracellular penetration and acts directly on the body of leishmania. Due to its anti-inflammatory effect, immediate relief in clinical symptoms was seen in our patient.[3] Oral route of administration, lack of major adverse effects, low cost, and easy availability make doxycycline a good alternative option in the treatment of leishmaniasis. Radio frequency, thermotherapy, and hand-held exothermic crystallization thermotherapy are also being tried for these cases.[4] A combination of allopurinol plus meglumine antimoniate has also proved to be effective.[5]

Cutaneous leishmaniasis should no longer be a neglected tropical disease. High index of clinical suspicion is needed to diagnose and treat the condition to prevent undue morbidity. Further research studies are needed to know the exact mechanism of action of doxycycline and its efficacy in leishmaniasis.

Declaration of patient consent

The authors certify that appropriate patient consent was obtained.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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