A 78 yr old man from a rural area at the western of Iran referred to Razi Hospital Dermatology Clinic, Tehran for multiple ulcerative and exudative lesions on mid face, dorsal aspect of hands and the posterior aspect of heels (Fig. 1, 2).
Informed consent was taken from the patient.
Lesions initiated three years before with papules on the dorsal aspect of the hands then progressively enlarged above the upper lip, anterior portion of the nasal fossa, above the eyebrows and heels and became ulcerative.
During the past 3 yr, the lesions of hands were so developed that destroyed the tendons and soft tissue of fifth finger in the right hand so led to amputation of this finger. There was no history of comorbid condition, drug consumption, systemic symptoms, weight loss, fever, lymphadenopathy, hepatosplenomegaly or any signs of systemic involvement in physical examination and laboratory survey.
Multiple treatments in order to some heterogenic diagnosis such as pyoderma gangrenosum, sarcoidosis, and leishmaniasis were tried without any improvement in lesions.
In Razi Hospital Dermatology Clinic, initial Skin biopsy revealed necrotizing and palisading granulomatous tissue pattern that suggested infections etiology but the smear of lesions for fungal and mycobacteria and Leishmania was negative. In order to result of PPD test with 27 mm induration, anti-tuberculosis treatment including isoniazid, rifampin, ethambutol, and pyrazinamide was started.
A month after initiating drugs for tuberculosis, the smear of leishmaniasis repeated that was positive this time, the second biopsy revealed pseudoepitheliomatous hyperplasia and infiltration of the dermis by mixed inflammatory cells and Leishman bodies compatible with leishmaniasis.
Restriction fragment length polymorphism (RFLP) PCR was carried out on DNA extraction was carried out with QIAGEN Kit according to the manufacturer's instruction using two primers, LITSR (5-GTG CAG GAT CAT TTT CCG ATG) and L5.8s: 5-TGA TAC CAC TTA TCG CAC TT was designed for LTS1-PCR and cutting with and HaeIII enzyme. Positive controls containing DNA of L. major, L. tropica and a negative control containing distilled water were included. The PCR-RFLP on specimens of lesions proved L. major as the pathogenic agent (Fig. 3).
From the left side, the 2 bands show L. major, the second 2 bands show L. tropica, the 5th one is the specimens of lesions that compatibles with L. major and the last one show L. tropica.
Treatment initiated with 3 gr per day of meglumine antimoniate (Glucantime ) until 1 wk followed by 4.5 gr per day for another week, in spite of good response to meglumine antimoniate after 2 wk of treatment we forced to discontinue of drug because of cardiac toxicity (Figs. 4, 5).
The patient was informed about publishing his figures whit covering eyes.