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6. Hvysjuka, O. M., Hvysjuka, M. I., Marchenko, V. G. (2013). Suchasna pisljadyplomna osvita: dosjagnennja, prob-
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1. Introduction and literature review
Cutaneous leishmaniasis is an old parasitic disease caused by obligate intracellular protozoans from the genus Leishmania [1]. It is typically transmitted to human through the bite of infected female sand fly of the genus Phlebotomus in the Old World and Lutzomyia in the New World [2]. Cutaneous leishmaniasis is endemic in Saudi Arabia, according to World Health Organization (WHO) 2,549 cases were reported in 2009 [3, 4]. The clinical forms of leishmaniasis are categorized into three forms: cutaneous leishmaniasis, mucocutaneous leishmaniasis and visceral leishmaniasis [3]. Cutaneous leishmaniasis usually present with painless nodules, plaques, ulcers, or noduloulcerative lesions on exposed body parts [5]. The main differential diagnosis of cutaneous leishmaniasis include acute bacterial infection, fungal infection, mycobac-terial infection, arthropodbite, sarcoidosis, syphilis and skin cancer [6, 7]. In the literatures, there were few case
lemy, perspektyvy: materialy navchal'no-naukovoi' konfer-encii'. Kharkiv: «Oberig», 230.
reports from endemic areas about cutaneous infections that have been misdiagnosed as cutaneous leishmaniasis. AlKhodair and Al-Khenaizan, reported a case of a Saudi male who presented with a chronic, nonhealing ulcer at his right elbow and was misdiagnosed and mistreated as cutaneous leishmaniasis. This patient was finally diagnosed as fish tank granuloma that responded well to oral antibiotics [8]. Verma S. et al. reported two cases from sub-Himalayan region, presented with chronic, nonhealing facial lesions that were misdiagnosed and mistreated as cutaneous leishmaniasis. The patients were finally diagnosed as facial chromoblastomycosis [9].
Here, we report a Sudanese male who presented with chronic, ulcerated cutaneous lesions that was misdiagnosed and mistreated as cutaneous leishmaniasis. Being in an endemic area, other differential diagnosis was overlooked and the case was finally diagnosed to be staphylococcal ecthy-ma that successfully responded to oral antibiotic.
Рекомендовано до публжацп д-р мед. наук, професор Гарюк Г. I.
Дата надходження рукопису 13.02.2015
Потапов Ернест Вжторович, кандидат медичних наук, кафедра отоларшгологп та дитячо! отоларингологи, Харшвська академiя тслядипломно! освгги, вул. Корчагшщв, 58, г. Харьков, Укра!на, 61176 E-mail: erikua@gmail.com
616.5
10.15587/2313-8416.2015.39356
ECTHYMA MIMICKING CUTANEOUS LEISHMANIASIS © Moteb K. Alotaibi
Chronic non-healing ulcerated skin lesion can be a diagnostic dilemma for the dermatologist in an area endemic with cutaneous leishmaniasis. The differential diagnosis may include a large list of cutaneous diseases ranging from infection to advanced skin cancers. Ecthyma is cutaneous infection caused by group A beta-hemolytic streptococci or Staphylococcus aureus bacteria with dermal and subcutaneous invasion. Ecthyma is a differential diagnosis for cutaneous Leishmaniasis presenting as an ulcerated lesion in endemic areas. Being in endemic area for cutaneous leishmaniasis, general physicians and some dermatologist may miss other important and common differential diagnosis, resulting in delay ofproper management and increase risk of complications. Our aim in this work is to draw the attentions toward better management while dealing with ulcerated cutaneous lesions. Method: Case reporting.
Result: This is a case of a 60 year-old Sudanese male patient who presented with a chronic nonhealing ulcerated lesions at his right forearm for 4 months. The patient was misdiagnosed as a case of cutaneous leishmaniasis and he was treated with anti-leishmanial therapy with no improvement. He was finally diagnosed to have staphylococcal ecthyma that successfully responded to oral antibiotic.
Conclusion: Dealing with chronic ulcerated skin lesion requires a carful and detailed history taking and a good knowledge of the common and endemic diseases in the patient's area supported by proper laboratory studies Keywords: Ecthyma, cutaneous leishmaniasis, infection, leishmania
Хротчне незагойне згниле ураження шюри може бути д1агностичною проблемою для дерматолога в област1, ендем1чнш з1 шюрним лейшматозом. Тут ми повгдомляемо про випадок 60-р1чноХ суданського пащента чолов1чо'1 стат1, в якого спостер1галося хротчне незагойне згниле ураження шюри поразок на правому передплгччi протягом 4 м1сяц1в. У пащента був помилково д1агностований випадок штрного лейшматозу i вiн лiкувався антилейшматозною терапiею, яка не полтшила його стан Ключовi слова: ектима, шюрний лейшматоз, iнфекцiя, лейшматя
2. The case
A 60 year-old Sudanese male presented to the dermatology clinic of King Fahd Hospital of the University with two chronicnonhealing ulcerated lesion at his right forearm for 4 months.The lesion started as an erythem-atous symptomless papule that graduallyenlarged to a nodule and became ulcerateddischarging pus. The patient was diagnosed as a case of cutaneous leishmaniasisat a private clinic and sodium stibogluconate intramuscular for fourteen days was given.According to the patient, he did not notice any improvement in his condition the following weeks, sointralesionalsodium stibogluconate was given once. During the following three months, the ulcer continued to enlarge in width and depth with pus discharge mixed with blood (Fig. 1).
Fig. 1. The right forearm revealing ulcer with purulent, discharge and surrounding erythema
There was no fever or any other constitutional symptoms. On examination of the right forearm, there wastwo ulcers of 3 centimeters in its largest diameter, discharging purulent, bloody discharge and surrounded with erythema. There was no regional lymphadenopathy.He had no fever and systemic examination did not reveal any abnormality. At that time, our differential diagnosis was bacterial infection, fungal infection and cutaneous leishmaniasis. His laboratory investigations including complete blood count, erythrocyte sedimentation rate, liver enzymes and renal function tests were within normal limits. Swab from the discharge for bacterial culture revealed staphylococcus au-reus. Biopsy was cancelled since the tissue was so friable. So the condition was diagnosed as a case of staphylococcal ecthyma. The patient was started on amoxicillin and clavu-lanate potassium (Augmentin) 1gm every 12 hours daily for 2 weeks with daily wound care conducted by the nurse. After 4 weeks, the patient came with complete healing of the ulcer and post inflammatory hyperpigmentation.
3. Discussion
Cutaneous leishmaniasis is a chronic parasitic skin infection caused by protozoans from the genus
Leishmania. In Saudi Arabia, the most common form of leishmania infection is cutaneous leishmaniasis in central and eastern provinces and Leishmania tropica in western and southwestern provinces [3]. The main vector of the disease is Phlebotomus sergenti, and the disease affects males and females equally [3]. The disease mostly affects patients of 15-44 years of age mainly at the extremities; most patients have a single lesion, with less than 5 % showing multiple lesions on hands, legs, and face [3]. In our area, cutaneous leishmaniasis is one of the top of differential diagnosis list of any ulcerated skin lesion at any exposed body parts.
On the contrary, gram positive bacteria are responsible for the vast majority of skin infections [10]. However, staphylococcus aureus frequently colonizes the cutaneous and mucosal surfaces. In the United States, it is estimated that approximately 30 % of healthy individuals are colonized in the skin or mucosa with staphylococcus aureus [10].
Ecthyma is a cutaneous infection with dermal and potentialsubcutaneous extension. It is commonly caused by group A beta-hemolytic streptococci or staphylococcus aureus. The lesion usually starts as vesicles or pustules with a grey-yellow crust that evolves into shallow punched-out ulcers with a necrotic base when the adherent crust is removed. Hemorrhagic crust can be present and the lesion eventually heals with scarring. Fever and regional lymph-adenopathy can be prominent clinical features [11, 12]. Ecthyma occurs most commonly on the feet, legs, thighs and buttocks, but any site can be affected [12]. Factors predisposing to ecthyma include, environments with poor hy-bloody giene, low socio-economic status, malnutrition, tropical climate and immunodeficiency. It can evolvesfrom impetigo that has not been properly treated or within a pre-existing dermatosis, site of trauma, arthropodbite and lesions of scabies [11, 12]. Ecthymagangrenosum is a rare variant, typicallycaused by pseudomonas aeruginosa, an aerobic gram-negative bacteria. It usually occurs in neutropenic or immuno-compromised patients with pseudomonas septicaemia [13]. The diagnosis of ecthyma is confirmed by gram stain and culture of the exudate [14]. Oral penicillinase-resistant penicillin or first-generation cephalosporins are usually effective as most staphylococcal infections are methicillin susceptible. Alternatives for penicillin-allergic patients or infections with Methicillin-resis-tant Staphylococcus aureus (MRSA) include doxycy-cline, clindamycin or Trimethoprim-sulfamethoxazole (SMX-TMP) [13].When streptococci alone are isolated, penicillin is the drug of choice, with a macrolide or clinda-mycin as an alternative for penicillin-allergic patients [14].
In conclusion, this is a patient who presented with staphylococcal ecthyma at his right forearm.It has been misdiagnosed as resistant cutaneous leishmaniasis. Amoxicillin and clavulanate potassium (Augmentin) 1gm every 12 hours daily for 2 weeks with daily wound care were successful in clearing the infection.
4. Acknowledgment
I would like to acknowledge Professor Iqbal Bukhari for her valuable support in writing this report.
References
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References
1. Clem, A. (2010). A current perspective on leishmaniasis. Journal of Global Infectious Diseases, 2 (2), 124-126. doi: 10.4103/0974-777x.62863
2. Stockdale, L., Newton, R. (2013). A Review of Preventative Methods against Human Leishmaniasis Infection. PLoS Neglected Tropical Diseases, 7 (6), e2278. doi: 10.1371/ journal.pntd.0002278
3. Salam, N., Al-Shaqha, W. M., Azzi, A. (2014). Leishmaniasis in the Middle East: Incidence and Epidemiology. PLoS Neglected Tropical Diseases, 8 (10), e3208. doi: 10.1371/ journal.pntd.0003208
4. Amin, T. T., Al-Mohammed, H. I., Kaliyadan, F., Mohammed, B. S. (2013). Cutaneous leishmaniasis in Al Has-sa, Saudi Arabia: Epidemiological trends from 2000 to 2010. Asian Pacific Journal of Tropical Medicine, 6( 8), 667-672. doi: 10.1016/s1995-7645(13)60116-9
5. Bari, A., Rahman, S. (2006). Correlation of clinical, his-topathological, and microbiological findings in 60 cases of cutaneous leishmaniasis. Indian Journal of Dermatology, Venereology and Leprology, 72 (1), 28-21. doi: 10.4103/0378-6323.19714
6. Markle, W. H., Makhoul, K. (2004). Cutaneous leish-maniasis: recognition and treatment. Am Fam Physician, 15, 69 (6), 1455-1460.
7. Pavli, A., Maltezou, H. C. (2010). Leishmaniasis, an emerging infection in travelers. International Journal of Infectious Diseases, 14 (12), e1032-e1039. doi: 10.1016/ j.ijid.2010.06.019
8. AlKhodair, R., Al-Khenaizan, S. (2010). Fish tank granuloma: misdiagnosed as cutaneous leishmaniasis. International Journal of Dermatology, 49 (1), 53-55. doi: 10.1111/ j.1365-4632.2009.04239.x
9. Verma, S., Verma, G. K., Singh, G., Kanga, A., Shar-ma, V., Gautam, N. (2012). Facial chromoblastomycosis in sub-Himalayan region misdiagnosed as cutaneous leishmania-sis: brief report and review of Indian literature. Dermatol Online J. 15, 18 (10), 3.
10. Krishna, S., Miller, L. S. (2012). Host-pathogen interactions between the skin and Staphylococcus aureus. Current Opinion in Microbiology, 15 (1), 28-35. doi: 10.1016/ j.mib.2011.11.003
11. Orbuch, D. E., Kim, R. H., Cohen, D. E. (2014). Ecthyma: a potential mimicker of zoonotic infections in a returning traveler. International Journal of Infectious Diseases, 29, 178-180. doi: 10.1016/j.ijid.2014.08.014
12. Empinotti, J. C., Uyeda, H., Ruaro, R. T., Galhardo, A. P., Bonatto, D. C. (2012). Pyodermitis, An Bras Dermatol., 87 (2), 277-284.
13. Motswaledi, M. (2011). Superficial skin infections and the use of topical and systemic antibiotics in general practice. South African Family Practice, 53 (2), 139-142. doi: 10.1080/20786204.2011.10874073
14. Stevens, D. L., Bisno, A. L., Chambers, H. F., Dellinger, E. P., Goldstein, E. J. C., Gorbach, S. L. et. al. (2014). Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 59 (2), e10-e52. doi: 10.1093/cid/ciu296
Дата надходження рукопису 17.02.2015
Moteb K. Alotaibi, MD, Unaizah College of Medicine and Medical Sciences, Qassim University, Po Box 991, Unaizah, Alqassim, 51911, Saudi Arabia E-mail: Moteb.a@gmail.com
