Hi
I have a case with raised reddish lesion in her right leg near the foot that is inflamed with exudate discharge that likely to be cutaneous leishmaniasis. In history she eats antibiotics and her lesion became worse and three months ago she went to endemic area of leishmanasis, I personally took samples from different parts of the lesion mostly marginal part of that and stained with gimsa.
And amastigotes are not seen, but there are many neutrophils are seen, I take the sample with Lancet and lesion is bleeding,
In your opinion, what is the cause of that?
Dear Sir , you can consult senior pathologists to diagnose obscure lesion .
Dear Dr Faridi,
I recommend to take a 4 mm (diameter), 4-5 mm deep punch biopsy from the wound margin, right were the ulceration meets the intact epidermis. Then you take a scalpel and divide the tissue cylinder in two halfs, in line with the punch axis, so both halfs have all tissues layers, from epidermis to subcutis. One half, you put into 5% formalin and send to your pathologist for HE staining. The other half you put in NaCl 0.9% and send for PCR for leishmania.
Hope that helps!
Cutaneous leishmaniasis takes many forms that vary with species and genotype of the parasite, as well as conditions of the host, etc. The same is true for other cutaneous pathogens that form surface or subsurface lesions. The only definitive way is to perform a biopsy to examine the parasite more closely. The simplest method following biopsy is a standard stained smear or histological section, from which you can discern the characteristic amastigote stages scattered among the host cells or within the host cells, especially tissue macrophages. Many photographic diagnostic atlases are available to assist with this, and you can also find images on the web. I've attached a couple of images of Leishmania from biopsies of visceral leishmaniasis of the spleen and liver. The appearance of amastigotes in these are similar to what you would see in skin biopsies for any of the cutaneous and mucocutaneous Leishmania species.
Thank you David Bruce Conn Yes plus the clinical picture the appearance of amastigotes in the skin biopsy can differentiate
Dear Dr. Faridi,
If you prepare imprints from a good biopsy sample and stain it with Giemsa or Wright you can identify the Leishmania amastigotes by their characteristic morphology (round or oval form with a nucleous and kinetoplast). Usually, most of the parasite are found outside of macrophages. For specific identification you can use PCR directly from skin biopsy or culture isolated parasite.
Dear Mário Steindel ·I agreed with you. However PCR needs experience and some more facility
Dear Dr Faridi,
diagnosis of cutaneous leishmaniasis is based on clinic o-pathological correlation.
Typical clinical cases were those who had discrete papules, nodules or non-healing nodulo-ulcerative skin lesions if they met at least four of the following five clinical criteria:
1. origin from a known endemic area, or have visited an
endemic area during the period of onset of the lesion
2. painless and non itchy lesions
3. duration of several weeks to a month
4. resistant to conventional antibiotics
5. history of similar lesions in the household or locality
Atypical CL lesions, i.e. non healing ulcers, punched out ulcers and large plaques having four of the five above clinical criteria were considered as clinically suggestive lesions.
PCR positivity is the gold standed.
Reference: Ranawaka RR, Abeygunasekara PH, Weerakoon HS. Correlation of Clinical, Parasitological and Histopathological diagnosis of Cutaneous Leishmaniasis in an Endemic Region in Sri Lanka. Ceylon Medical Journal 2012 Dec; 57(4):149-152 PMID: 23292056
Thanks everybody, according to my Descriptions of the lesion and patient, she travels to endemic area of cutaneous leishmaniasis, and antibiotics worst the ulcer, I take the sample but I don’t see the leishmania, last week from date I ask the question I see amastigoe of leishmania in one other patent, I asked what the other agent cause lesion looks like cutaneous lishmania (but there is no amastigot in there) is?. Regards to I know PCR is gold standard but I don’t have set up procedure for that.
Thanks again dear everybody.
Dear Dr.Faridi;
It seems that the lesion is CL but it has secondary infection that is the main reason for negative stain, because you will find a lot of `neutrophils, but you can't find the amastigote actually this is rule so you can go through NNN culture or you have to know what is the effective antibiotic for her lesion (I think she took the wrong one) so go through sensitivity test, let her use the right one than back to biopsy examination,
According to WHO recommendations you should avoid the blood (adrenaline), take the biopsy under the crust not from the margins, try to examine about 3 slides to confirm the case. Good luck,
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