Chronic paronychia as a manifestation of skin leishmaniasis

A 42-year-old male, who was a rural worker in the municipality in the interior of Amazonas, Brazilian state, presented with swelling, erythema, and infiltration of ungual folds with eroded surface and scales on the right ring finger along with fever and pain for 45 days (Figure 1). Direct smear of the lesion, stained with Giemsa showed the presence of amastigote forms of Leishmania parasite upon microscopic examination, thereby diagnosing it as a case of cutaneous leishmaniasis (LC) (Figure 2). The patient was administered with miltefosine for 28 days but showed therapeutic failure 60 days after the treatment ended. Thereafter, pentavalent antimony (Sb^v) was administered at 20mg/kg daily total dose for 20 days, which resulted in complete cure (Figure 3). Initial therapy was conducted using miltefosine because the patient was part of a multicenter clinical trial that evaluated the effectiveness of this drug in combination with a topical immunomodulator.

FIGURE 1:
Erythematous swelling with scales and eroded surface in the nail fold of the right ring finger.

FIGURE 2:
Slit-skin smear showing the presence of amastigote forms of the Leishmania parasite. Giemsa staining, original magnification 100x.

FIGURE 3:
Clinical inspection of the lesion after six months of treatment, showing atrophic scarring and improvement of the ungual plate.

CL is endemic in the Amazonas State and in most cases, it is caused by Leishmania (Viannia) guyanensis¹, exhibiting low response to Sb^v treatment with only 53% of cure rate². The classical evolution of this disease is characterized by the emergence of ulcers with infiltrated regular and elevated edges³, but atypical forms have also been described³.

Despite the diversity of clinical presentations in leishmaniasis, paronychia, known as inflammation of the ungual folds, is poorly described, with only nine reports on PubMed. It is important to diagnose this disease, mainly in endemic regions, given the possibility of occurrence of permanent ungual dystrophy if the diagnosis and treatment are delayed.

ACKNOWLEDGMENTS

We offer our deepest thanks to the institutions that provided technical support for the development and implementation of this study.

References

• ¹
  De Guerra JAO, Maciel MG, De Guerra MVF, Talhari AC, Prestes SR, Fernandes MA, et al. Tegumentary leishmaniasis in the state of amazonas: What have we learned and what do we need? Rev Soc Bras Med Trop. 2015;48(Suppl 1):12-9.
• ²
  Chrusciak-Talhari A, Dietze R, Talhari CC, Da Silva RM, Yamashita EPG, De Oliveira Penna G, et al. Randomized controlled clinical trial to access efficacy and safety of miltefosine in the treatment of cutaneous leishmaniasis caused by Leishmania (Viannia) guyanensis in Manaus, Brazil. Am J Trop Med Hyg. 2011;84(2):255-60.
• ³
  Meireles CB, Maia LC, Soares GC, Teodoro IPP, Gadelha M do SV, da Silva CGL, et al. Atypical presentations of cutaneous leishmaniasis: A systematic review. Acta Trop. 2017;172:240-54.

Publication Dates

• Publication in this collection
  08 Mar 2021
• Date of issue
  2021

History

• Received
  03 Sept 2020
• Accepted
  29 Sept 2020