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Erythematous Nodule of the Left Eyebrow in a 14-Year-Old Boy

Erythematous Nodule of the Left Eyebrow in a 14-Year-Old Boy Case A 14-year-old boy was referred to our unit for evaluation of mild to moderate papulopustular acne. He also presented a slowly enlarging erythematous nodule located on the left eyebrow, which was initially attributed to the underlying disease. The lesion had started 6 months before referral. The patient’s medical history was unremarkable. Physical examination revealed an erythematous, nodular, oval-shaped lesion, approximately 12 × 6 mm in diameter, with a warty surface and a tense-elastic consistence on palpation (Figure, A). There was no pain when fingertip pressure was applied. Dermoscopy revealed the presence of a nonspecific vascular pattern with “polymorphous” vessels and multiple yellow-white areas (Figure, B [arrowheads]). A biopsy specimen was obtained (Figure, C). Figure. View LargeDownload A, Clinical photograph at presentation. B, Findings from dermoscopy. C, Histological analysis of the biopsy specimen (hematoxylin-eosin, original magnification ×100). What is your diagnosis? Read the Discussion. Discussion Diagnosis Cutaneous leishmaniasis (CL) Microscopic Findings and Clinical Course A biopsy specimen from the peripheral part of the left eyebrow was obtained, stained with hematoxylin-eosin, and examined under light microscopy (Figure, C). Histological examination found a granulomatous infiltrate with mononuclear cells and multiple amastigotes, which are diagnostic for leishmania and permitted us to make a correct diagnosis. Cutaneous leishmaniasis is a protozoan skin infection caused by various species of Leishmania (Leishmania major and Leishmania tropica are the most common), transmitted by infected animals to humans through the bite of Phlebotomine sandflies (old world) and Lutzomyia (new world).1 Cutaneous leishmaniasis is widely distributed and is considered the most common parasitic infection worldwide, after malaria. It is prevalent in Africa, the Middle East, Latin America, and Mediterranean areas, and its incidence is more than 1.5 million cases per year.2 In Italy, it is endemic or hypoendemic in Sardinia, Sicily, and Campania. The clinical spectrum of CL is determined by the type of Leishmania, and the immune system of the patient affected ranges from self-resolving cutaneous lesions to nonhealing noduloulcerative lesions. Clinically, CL appears as small papules that can progress into erythematous nodules or indurate scaly plaques or into ulcers with regular contours and a central crust that often tends to be hemorrhagic. The lesions are usually found in exposed areas, especially the face and arms, after a period of incubation of a few weeks to months.3 The presence of a nonulcerated nodule did not allow us to perform the analysis of tissue scraping with direct visualization of the parasite. So the first examination that we made was the dermoscopy, which revealed the presence of a generalized erythema with a nonspecific vascular pattern and “yellow tears,” which are characteristic signs of CL.4 The most common pattern of CL on the head is characterized by vascular structures and yellow tears.4 However, in this area, the relevant finding is the presence of vascular structures that could be found in a wide variety of benign and malignant tumors. The absence of melanocytic criteria permitted us to exclude Spitz or Reed nevus and amelanotic melanoma. These dermoscopic findings allowed us to perform a biopsy for confirming the clinical suspicion of CL. Another differential diagnosis to consider is the pyogenic granuloma, which shows a reddish homogeneous area surrounded by a white collarette, without the presence of vascular pattern. No culture and polymerase chain reaction–based methods were assessed for the specification of Leishmania species. Treatment of CL diseases includes thermotherapy and various pharmacologic therapies such as pentavalent antimony (sodium stibogluconate or meglumine antimonate), pentamidine, paromomycin, amphotericin B, and some azoles such as fluconazole, ketoconazole, and itraconazole.1-5 A randomized, double-blind, parallel group–controlled study in 375 patients from a region of Tunisia, where leishmaniasis is endemic, demonstrated that paromomycin topical cream, with or without gentamicin, is effective against CL.5 This was the therapy we chose because it was noninvasive and less expensive compared with other treatments such as thermotherapy. We obtained a significant improvement of the clinical picture after 8 weeks of therapy, with no relapsing after 16 weeks of follow-up. We believe that dermoscopy can be considered a useful instrument for the early diagnosis of CL. Back to top Article Information Corresponding Author: Beatrice Raone, MD, Division of Dermatology, Department of Specialized, Experimental and Diagnostic Medicine, Sant’Orsola–Malpighi Hospital, University of Bologna, Via Massarenti 1, 40138 Bologna, Italy (beatrice.raone@libero.it). Published Online: December 18, 2013. doi:10.1001/jamadermatol.2013.5965. Conflict of Interest Disclosures: None reported. Section Editor: Mary S. Stone, MD; Assistant Section Editors: Soon Bahrami, MD; Carrie Ann R. Cusack, MD; Molly A. Hinshaw, MD; Arni K. Kristjansson, MD; Lori D. Prok, MD. References 1. Singh N, Kumar M, Singh RK. Leishmaniasis: current status of available drugs and new potential drug targets. Asian Pac J Trop Med. 2012;5(6):485-497.PubMedGoogle ScholarCrossref 2. David CV, Craft N. Cutaneous and mucocutaneous leishmaniasis. Dermatol Ther. 2009;22(6):491-502.PubMedGoogle ScholarCrossref 3. Goto H, Lindoso JA. Current diagnosis and treatment of cutaneous and mucocutaneous leishmaniasis. Expert Rev Anti Infect Ther. 2010;8(4):419-433.PubMedGoogle ScholarCrossref 4. Llambrich A, Zaballos P, Terrasa F, Torne I, Puig S, Malvehy J. Dermoscopy of cutaneous leishmaniasis. Br J Dermatol. 2009;160(4):756-761.PubMedGoogle ScholarCrossref 5. Ben Salah A, Ben Messaoud N, Guedri E, et al. Topical paromomycin with or without gentamicin for cutaneous leishmaniasis. N Engl J Med. 2013;368(6):524-532.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Dermatology American Medical Association

Erythematous Nodule of the Left Eyebrow in a 14-Year-Old Boy

Raone, Beatrice; Raboni, Roberta; Ismaili, Alma
JAMA Dermatology , Volume 150 (2) – Feb 1, 2014
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Publisher
American Medical Association
Copyright
Copyright © 2014 American Medical Association. All Rights Reserved.
ISSN
2168-6068
eISSN
2168-6084
DOI
10.1001/jamadermatol.2013.5965
pmid
24352301
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Abstract

Case A 14-year-old boy was referred to our unit for evaluation of mild to moderate papulopustular acne. He also presented a slowly enlarging erythematous nodule located on the left eyebrow, which was initially attributed to the underlying disease. The lesion had started 6 months before referral. The patient’s medical history was unremarkable. Physical examination revealed an erythematous, nodular, oval-shaped lesion, approximately 12 × 6 mm in diameter, with a warty surface and a tense-elastic consistence on palpation (Figure, A). There was no pain when fingertip pressure was applied. Dermoscopy revealed the presence of a nonspecific vascular pattern with “polymorphous” vessels and multiple yellow-white areas (Figure, B [arrowheads]). A biopsy specimen was obtained (Figure, C). Figure. View LargeDownload A, Clinical photograph at presentation. B, Findings from dermoscopy. C, Histological analysis of the biopsy specimen (hematoxylin-eosin, original magnification ×100). What is your diagnosis? Read the Discussion. Discussion Diagnosis Cutaneous leishmaniasis (CL) Microscopic Findings and Clinical Course A biopsy specimen from the peripheral part of the left eyebrow was obtained, stained with hematoxylin-eosin, and examined under light microscopy (Figure, C). Histological examination found a granulomatous infiltrate with mononuclear cells and multiple amastigotes, which are diagnostic for leishmania and permitted us to make a correct diagnosis. Cutaneous leishmaniasis is a protozoan skin infection caused by various species of Leishmania (Leishmania major and Leishmania tropica are the most common), transmitted by infected animals to humans through the bite of Phlebotomine sandflies (old world) and Lutzomyia (new world).1 Cutaneous leishmaniasis is widely distributed and is considered the most common parasitic infection worldwide, after malaria. It is prevalent in Africa, the Middle East, Latin America, and Mediterranean areas, and its incidence is more than 1.5 million cases per year.2 In Italy, it is endemic or hypoendemic in Sardinia, Sicily, and Campania. The clinical spectrum of CL is determined by the type of Leishmania, and the immune system of the patient affected ranges from self-resolving cutaneous lesions to nonhealing noduloulcerative lesions. Clinically, CL appears as small papules that can progress into erythematous nodules or indurate scaly plaques or into ulcers with regular contours and a central crust that often tends to be hemorrhagic. The lesions are usually found in exposed areas, especially the face and arms, after a period of incubation of a few weeks to months.3 The presence of a nonulcerated nodule did not allow us to perform the analysis of tissue scraping with direct visualization of the parasite. So the first examination that we made was the dermoscopy, which revealed the presence of a generalized erythema with a nonspecific vascular pattern and “yellow tears,” which are characteristic signs of CL.4 The most common pattern of CL on the head is characterized by vascular structures and yellow tears.4 However, in this area, the relevant finding is the presence of vascular structures that could be found in a wide variety of benign and malignant tumors. The absence of melanocytic criteria permitted us to exclude Spitz or Reed nevus and amelanotic melanoma. These dermoscopic findings allowed us to perform a biopsy for confirming the clinical suspicion of CL. Another differential diagnosis to consider is the pyogenic granuloma, which shows a reddish homogeneous area surrounded by a white collarette, without the presence of vascular pattern. No culture and polymerase chain reaction–based methods were assessed for the specification of Leishmania species. Treatment of CL diseases includes thermotherapy and various pharmacologic therapies such as pentavalent antimony (sodium stibogluconate or meglumine antimonate), pentamidine, paromomycin, amphotericin B, and some azoles such as fluconazole, ketoconazole, and itraconazole.1-5 A randomized, double-blind, parallel group–controlled study in 375 patients from a region of Tunisia, where leishmaniasis is endemic, demonstrated that paromomycin topical cream, with or without gentamicin, is effective against CL.5 This was the therapy we chose because it was noninvasive and less expensive compared with other treatments such as thermotherapy. We obtained a significant improvement of the clinical picture after 8 weeks of therapy, with no relapsing after 16 weeks of follow-up. We believe that dermoscopy can be considered a useful instrument for the early diagnosis of CL. Back to top Article Information Corresponding Author: Beatrice Raone, MD, Division of Dermatology, Department of Specialized, Experimental and Diagnostic Medicine, Sant’Orsola–Malpighi Hospital, University of Bologna, Via Massarenti 1, 40138 Bologna, Italy (beatrice.raone@libero.it). Published Online: December 18, 2013. doi:10.1001/jamadermatol.2013.5965. Conflict of Interest Disclosures: None reported. Section Editor: Mary S. Stone, MD; Assistant Section Editors: Soon Bahrami, MD; Carrie Ann R. Cusack, MD; Molly A. Hinshaw, MD; Arni K. Kristjansson, MD; Lori D. Prok, MD. References 1. Singh N, Kumar M, Singh RK. Leishmaniasis: current status of available drugs and new potential drug targets. Asian Pac J Trop Med. 2012;5(6):485-497.PubMedGoogle ScholarCrossref 2. David CV, Craft N. Cutaneous and mucocutaneous leishmaniasis. Dermatol Ther. 2009;22(6):491-502.PubMedGoogle ScholarCrossref 3. Goto H, Lindoso JA. Current diagnosis and treatment of cutaneous and mucocutaneous leishmaniasis. Expert Rev Anti Infect Ther. 2010;8(4):419-433.PubMedGoogle ScholarCrossref 4. Llambrich A, Zaballos P, Terrasa F, Torne I, Puig S, Malvehy J. Dermoscopy of cutaneous leishmaniasis. Br J Dermatol. 2009;160(4):756-761.PubMedGoogle ScholarCrossref 5. Ben Salah A, Ben Messaoud N, Guedri E, et al. Topical paromomycin with or without gentamicin for cutaneous leishmaniasis. N Engl J Med. 2013;368(6):524-532.PubMedGoogle ScholarCrossref

Journal

JAMA Dermatology – American Medical Association

Published: Feb 1, 2014

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