Case Report
Open Access
Cutaneous Leishmaniasis Following Local Trauma: A Case
Report
Marcela ST. Mendes1, Daniel G2, Jefferson BP. Ribeiro2, Adriana OS. Alfani2, Beatriz D. Lima3,
Carmen DR. Paula1, Ciro M. Gomes1 and Raimunda NR. Sampaio2*
1
Hospital Universitario de Brasilia, Universidade de Brasilia, Brasilia, Brazil
2 Departamento de Ciencias Medicas, Universidade de Brasilia, Brasilia, Brazil
3 Departamento de Biologia Celular, Universidade de Brasilia, Brasilia, Brazil
2 Departamento de Ciencias Medicas, Universidade de Brasilia, Brasilia, Brazil
3 Departamento de Biologia Celular, Universidade de Brasilia, Brasilia, Brazil
*Corresponding authors address: Raimunda Nonata Ribeiro Sampaio, Professor, SHIS QI 25, conj 02, casa 01, Brasilia, Distrito Federal, 71660-220, Tel: +55-61-
8121-6100; E-mail:
@
Received: 23 August, 2014; Accepted: 06 October, 2014; Published: 15 October, 2014
Citation: Mendes MST, Daniel G, Ribeiro JBP, Alfani AOS, Lima BD, et al. (2014) Cutaneous Leishmaniasis Following Local Trauma: A
Case Report. Clin Res Dermatol Open Access 1(1): 1-3. DOI: http://dx.doi.org/10.15226/2378-1726/1/1/00105
In Brazil there is an average of 30,000 cases of Cutaneous
Leishmaniasis reported annually, and around the world it happens
for about each 20 seconds. Although there are still opportunities
to contribute with studies about this disease; supporting the
medical community, especially dermatologists, mainly because
of the necessity of knowing that a relatively simple procedure
can result such a relevant trauma. Female patients presented
erythematous plaque in the limb. Lesion appeared days after laser
sessions for hair removal. Biopsy showed amastigotes forms and
positive culture. After unsuccessful treatment it was managed with
N-methyl glucamine 20 mgSbV/kg/day, during 20 days, there was
significant improvement of the clinical picture. This study aims to
present a case report of Cutaneous Leishmaniasis initiated after
local trauma. Literature reports describe primary or secondary
lesions of Cutaneous Leishmaniasis elicited after a local trauma. The
mechanism used in order to explain these events was the migration
of infected macrophages induced by cytokines. Similar events
have also been reported as part of the locus minoris resistentiae
concept that comprises situations in which microorganisms have a
tendency to settle at places of weakened resistance. Considering that
Leishmaniasis lesions are usually developed in promastigote forms
are inoculated by the Phlebotominae, in this case it was noted that the
infection has been favored by the local trauma.
Keywords:Public Health; Dermatology; Cutaneous leishmaniasis; Leishmania; Local trauma; Lesion; Skin
Keywords:Public Health; Dermatology; Cutaneous leishmaniasis; Leishmania; Local trauma; Lesion; Skin
Considered to be an emergent disease, Cutaneous
Leishmaniasis (CL) happens every 20 seconds in the world. In
Brazil an average of 30,000 cases are notified annually [1]. Even
though, the certain about its pathogenesis is not enough yet [2].
Gender, skin temperature [3], polymorphisms of the species
[2,4], host's immune response [4], site of inoculation [5] have
already being implicated, but poorly understood [5]. Thus, this
study aims to report a case of Cutaneous Leishmaniasis triggered
after local trauma.
A Thirty year-old information analyst, female patient, from Brasilia, Brazil, presented at our centre in November 7th, 2012,
with an erythematous ulcerated plaque with crusts in the lower
third of her right limb (Figure 1). The lesion started as a necrotic
patch a day after a Glass laser® session for hair removal in July 7th,
2012. She denied any recent trips before the event, but informed
that she usually visits the local botanic park. She was treated with
cephalexin and bacitracin ointment without improvement.
During the investigation, she was submitted to a skin biopsy that showed amastigotes inside histiocytes and inflammatory process (Figure 2). Smear and culture were positive. The Leishmania identified as Leishmania (Viannia) braziliensis was performed by Polymerase Chain Reaction (PCR), RFLP and sequencing of ribosomal DNA from region ITS1 [6]. The HIV serology was negative and the patient was not taking any immunosuppressant drugs. The investigation for fungi, mycobacteria and cutaneous tuberculosis was negative.
She was treated with 3 (three) doses of intramuscular pentamidine injections, 4 mg/kg/day. This treatment's choice was based on a clinical trial in course at our centre, after the patient's informed consent. As no improvement was obtained after three months of follow up, the patient was retreated with N-methyl glucamine 20 mgSbV/kg/day - 20 days, with complete healing of the ulcer (Figure 3).
During the investigation, she was submitted to a skin biopsy that showed amastigotes inside histiocytes and inflammatory process (Figure 2). Smear and culture were positive. The Leishmania identified as Leishmania (Viannia) braziliensis was performed by Polymerase Chain Reaction (PCR), RFLP and sequencing of ribosomal DNA from region ITS1 [6]. The HIV serology was negative and the patient was not taking any immunosuppressant drugs. The investigation for fungi, mycobacteria and cutaneous tuberculosis was negative.
She was treated with 3 (three) doses of intramuscular pentamidine injections, 4 mg/kg/day. This treatment's choice was based on a clinical trial in course at our centre, after the patient's informed consent. As no improvement was obtained after three months of follow up, the patient was retreated with N-methyl glucamine 20 mgSbV/kg/day - 20 days, with complete healing of the ulcer (Figure 3).
Several reports in literature describe primary or secondary
Figure 1: Erythematous ulcerated plaque with crusts in the lower third
of the right limb.
Figure 2: Histolopathological analysis: granulomatous inflammatory
process with macrophages containing amastigotes. Hematoxylin and
eosin stain (original magnification x 1000)
Figure 3: Complete healing of the ulcer.
lesions of CL elicited after local trauma [7-10]. In two experimental
models described, involving hamsters [3] and BALB/c mice
[11], it was observed an earlier and more frequent onset of
Leishmaniasis lesions where trauma was previously induced. The
mechanism used to explain these events would be the migration
of infected macrophages induced by inflammatory cytokines
[3,8,11]. The profile of these cytokines is also important, since
the tissue growth factor beta (TGFβ) is increased during tissue
repair. TGFβ is also implicated in macrophage inactivation, which
could favor the progression and recurrence of the disease [3,5].
Similar events have also been reported as part of the locus
minoris resistentiae concept that comprises situations in which
microorganisms have a tendency to settle at places of weakened
resistance, such as sites of trauma [12]. In other words, trauma
does not inoculate the parasite, but favors its fixation at that
site [13]. These reports identified this mechanism during
paracoccidioidomycosis [13], Pott's disease [14], parvovirus B19
[12], atypical mycobacteria [15] and Tricophyton mentagrophytes
infections [16].
On the reported case, an immunocompetent patient, that resides in an endemical area for CL (Distrito Federal, Brazil), and who did not have any clinical signs of the disease, is described. The patient developed CL lesion at the same site of the induced trauma, with short incubation period, as stated in literature [3,11]. The Leishmania species responsible for such lesions is already expected to be Leishmania (Viannia) braziliensis, since it is the most prevalent species in Brazil and in Distrito Federal [4,17].
Leishmaniasis is dynamic disease, as its transmission is continually changed in relation to environmental, demographic and human behavioural factors [18]. Considering that Leishmaniasis lesions are usually developed where promastigote forms are inoculated by the Phlebotominae [4]. The finding of Leishmaniasis lesions following trauma may contribute to a greater comprehension of the metastasis-like formation process during Leishmania infection. It may also alert dermatologists to the possibility of this event on such a frequent practice.
On the reported case, an immunocompetent patient, that resides in an endemical area for CL (Distrito Federal, Brazil), and who did not have any clinical signs of the disease, is described. The patient developed CL lesion at the same site of the induced trauma, with short incubation period, as stated in literature [3,11]. The Leishmania species responsible for such lesions is already expected to be Leishmania (Viannia) braziliensis, since it is the most prevalent species in Brazil and in Distrito Federal [4,17].
Leishmaniasis is dynamic disease, as its transmission is continually changed in relation to environmental, demographic and human behavioural factors [18]. Considering that Leishmaniasis lesions are usually developed where promastigote forms are inoculated by the Phlebotominae [4]. The finding of Leishmaniasis lesions following trauma may contribute to a greater comprehension of the metastasis-like formation process during Leishmania infection. It may also alert dermatologists to the possibility of this event on such a frequent practice.
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