1. Introduction
Leishmaniasis is a protozoal disease transmitted by sand-fly. The term leishmaniasis encompasses multiple clinical syndromes (1-3). Most notable ones are cutaneous, visceral and mucosal leishmaniasis. Traditionally, the term mucosal leishmaniasis refers to a potentially disfiguring sequel of the New World (America) cutaneous leishmaniasis those results from dissemination of parasites from the skin to the naso-oropharyngeal mucosa (3, 4). Leishmaniasis is endemic in Iran (Old World diseases) that usually affects only the skin and mucosal involvement is rare (1, 4-6).
This is to present a case of cutaneous leishmaniasis, which was interesting because of the rare location of the lesion and the fact that it can be confused with other infectious diseases (tuberculosis, leprosy and syphilis), neoplasms, sarcoidosis, and mucosal ulceration from cocaine use.
2. Case Presentation
A 24-year-old male referred to the infectious clinic with complaints of swelling and ulcer over his lower lip for three months. The patient had initially noticed a small raised lesion on the right corner of the lower lip which was not itchy and not painful. The swelling progressively increased in size over a few weeks and then its size was constant. The patient had no history of recent travel. There was no similar illness in his family.
There was no history of cigarette smoking or drugs addiction. Also, there was no history of fatigue, weight loss, appetite loss, cough or other complaints. Examination showed a small ulcer, indurated raised lesion on the right corner of the lower lip with well-defined edges but without pain and irritation (Figure 1).
Figure 1.
Before Treatment
The vital parameters (temperature and pulse rate) were normal and there was no hepatosplenomegaly or lymphadenopathy. Investigations showed a total leukocyte count of 6900/mm3 with polymorphonuclear 73% without eosinophilia or thrombocytopenia.
All other hematological and biochemical factors were normal. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), were normal. The HIV and VDRL were also tested by ELISA and results were also normal. The Mantoux test was within normal limits (5 mm).Ultimately, Giemsa-stained thin smear of lesion scraping revealed Leishman bodies (Figure 2) and diagnosis of lip leishmaniasis was made.
Figure 2.
Leishman Bodies
The patient was treated with intramuscularly sodium stibogluconate for 20 days (7). Patient responded very well and two weeks after the start of treatment regression in size started. The lesion completely healed without any residual pigmentation or scarring (Figure 3).
Figure 3.
After Treatment
The case was followed up for 12 months and showed no signs of relapse or lesion on other parts of the body.
3. Discussion
Lip lesion is seldom mentioned as presentation of cutaneous leishmaniasis in Iran (5, 6). Leishmaniasis may have various presentations, and factors affecting the disease spectrum include species and number of parasites, site of bite, and also nutritional status of the patient and the immune status (5, 6). Leishmaniasis of the skin may occur anywhere on the body but the usual sites are the exposed parts. Most patients have one or two ulcers, but the lesions may be multiple with various presentations (8). The cases of isolated lip leishmaniasis are seldom reported from Iran (9). The current case is reported since leishmaniasis is often diagnosed presumptively by clinical and epidemiologic criteria.
In endemic regions, considering the increasing spectrum of cutaneous leishmaniasis, a high clinical suspicion should always be observed to make the diagnosis while lesions are in lips (9, 10).
This case was interesting because of the rare location of the lesion and the fact that it can be confused with other infectious diseases (tuberculosis, leprosy and syphilis), neoplasms and sarcoidosis.
