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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.87 no.1 Rio de Janeiro Jan./Feb. 2012
IMAGING IN TROPICAL DERMATOLOGY
Ciro Martins GomesI; Orlando Oliveira de MoraisI; Anglya Samara Silva LeiteI; Killarney Ataíde SoaresII; Jorgeth de Oliveira Carneiro da MottaIII; Raimunda Nonata Ribeiro SampaioIV
IResident physician in Dermatology at the University Hospital of Brasilia, University of Brasilia (HUB-UnB), Brasilia (DF), Brazil
IIDegree in Pharmacy and Biochemistry, PhD in Medical Sciences, Faculty of Medicine, University of Brasilia (FM-UnB), Brasilia (DF), Brazil
IIIMaster in Health Sciences awarded by the University of Brasilia (UnB), Residency Preceptor of Dermatology, University Hospital of Brasilia, University of Brasilia (HUB-UnB), Brasilia (DF), Brazil
IVAssociate Professor at the University of Brasilia (UnB), Head of the Department of Dermatology, University Hospital of Brasilia (HUB-UnB), Brasilia (DF), Brazil
The vast majority of cases of cutaneous leishmaniasis are represented by limb injuries. A female patient, white, presented an ulcer with infiltrated borders located on the fourth finger of the left hand following occupational exposure in an area of native forest. Diagnosis of cutaneous leishmaniasis caused by Leishmania of the subgenus Viannia was confirmed. The patient failed to respond to treatment with antimony, but achieved clinical cure after this was associated with pentoxifylline. The case highlights the rarity of the periungual location of the leishmanial lesion and the difficulties encountered in therapy.
Keywords: Diagnosis; Leishmania braziliensis; Leishmaniasis, mucocutaneous; Polymerase chain reaction
A grande maioria dos casos de leishmaniose tegumentar é representada por lesões nos membros. Paciente feminina, branca, diabética, apresentou úlcera com bordas infiltradas, localizada no quarto quirodáctilo esquerdo, após exposição ocupacional em área de mata nativa. Foi confirmado o diagnóstico de leishmaniose tegumentar por Leishmania do subgênero Viannia. Não respondeu ao tratamento com antimonial, mas obteve cura clínica após associação com a pentoxifilina. O caso destaca-se pela raridade da localização periungueal da lesão leishmaniótica e pela dificuldade terapêutica.
Palavras-chave: Diagnóstico; Leishmania braziliensis; Leishmaniose mucocutânea; Reação em cadeia da polimerase
Female, 39 years, from the state of Mato Grosso (Brazil), diabetic. Thirty days after working in a rural area presented with a periungual ulcerated infiltration in the left-hand fourth finger (Figure 1).
Leishmania was positive on histopathology, smear and culture. Indirect immunofluorescence and Montenegro skin test was positive (1:40mm and 17 mm respectively). Polymerase Chain Reaction of exudate on filter paper confirmed presence of the Leishmania Viannia subgenus (Figure 2).1
The patient was treated with N-methylglucamine (15mgSbV/kg/day) for 20 days. 2,3 Ninety days later lesion showed incomplete healing and a new cycle of treatment combined with pentoxifylline 400mg 8/8 hours for 30 days was commenced, with resolution of the lesion (Figures 3 and 4).
The species of L(V.) braziliensis is endemic in the state of Mato Grosso (Brazil). 2 Refractoriness may be associated with comorbidities such as diabetes and association with pentoxifylline appears to be the best option, explained by immunological mechanisms. 4,5 The periungual location of the lesion is unusual and is most commonly reported following accidental inoculation in the laboratory. 6
The authors are grateful to Professor Ana Maria Ferreira Roselino, PhD. for conducting and interpreting the PCR assays and to Dr. Carmen Déa Ribeiro de Paula for her contributions to both the diagnosis and treatment of the patient.
1. Volpini AC, Passos VM, Oliveira GC, Romanha AJ. PCR-RFLP to identify Leishmania (Viannia) braziliensis and L. (Leishmania) amazonensis causing American cutaneous leishmaniasis. Acta Trop. 2004;90:31-7. [ Links ]
2. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Manual de Vigilância da Leishmaniose Tegumentar Americana. 2 ed. Brasília: Ministério da Saúde; 2007. 180 p. [ Links ]
3. Lima EB, Porto C, Motta JOC, Sampaio RNR. Tratamento da leishmaniose tegumentar americana. An Bras Dermatol. 2007;82:111-24. [ Links ]
4. Sadeghian G, Nilforoushzadeh MA. Effect of combination therapy with systemic glucantime and pentoxifylline in the treatment of cutaneous leishmaniasis. Int J Dermatol. 2006;45:819-21. [ Links ]
5. Machado PR, Lessa H, Lessa M, Guimaraes LH, Bang H, Ho JL, et al. Oral pentoxifylline combined with pentavalent antimony: a randomized trial for mucosal leishmaniasis. Clin Infect Dis. 2007;44:788-93. [ Links ]
6. Sampaio RN, de Lima LM, Vexenat A, Cuba CC, Barreto AC, Marsden PD. A laboratory infection with Leishmania braziliensis braziliensis. Trans R Soc Trop Med Hyg. 1983;77:274. [ Links ]
Ciro Martins Gomes
Hospital Universitário de Brasília
SGAN 605, Av. L2 Norte
Brasília - DF, Brazil CEP: 70910-900
Received on 26.12.2010.
Approved by the Advisory Board and accepted for publication on 13.03.2011.
Conflict of interest: None
Financial funding: None
* Study conducted at University Hospital of Brasilia, University of Brasilia (HUB-UnB), Brasilia (DF), Brazil.