Case for Diagnosis
Slow-growing Scaly Erythematous Plaque on the Face and Scalp of an Elderly Woman
Placa eritematodescamativa de lento crecimiento en la cara y el cuero cabelludo de una mujer anciana
Y. Torres Garcia, B. Escutia Muñoz, R. Botella Estrada
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Departamento de Dermatología, Hospital Universitario La Fe, Valencia, Spain
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Torres Garcia, B. Escutia Muñoz, R. Botella Estrada" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Y." "apellidos" => "Torres Garcia" ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Escutia Muñoz" ] 2 => array:4 [ "nombre" => "R." "apellidos" => "Botella Estrada" "email" => array:1 [ 0 => "botella_rafest@gva.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Dermatología, Hospital Universitario La Fe, Valencia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Placa eritematodescamativa de lento crecimiento en la cara y el cuero cabelludo de una mujer anciana" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 450 "Ancho" => 600 "Tamanyo" => 108432 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, ×400.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">An 89-year-old female with no known relevant medical history presented with an asymptomatic, scaly, erythematous, infiltrated plaque on the scalp and part of the face. The lesion had appeared about a year earlier and had gradually grown to its size at the time of presentation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient reported no systemic symptoms.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed a large, scaly, erythematous plaque on the left frontal and temporal region extending down to the left malar area and cheek. Areas of yellowish discoloration were observed in some parts of the lesion. Exophytic and keratotic lesions were present on the upper left side. There was no evidence of mucosal involvement and the patient's general condition was normal.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">At low magnification, a biopsy specimen from the edge of the lesion showed a slightly acanthotic and ulcerated but otherwise unremarkable epidermis as well as a granulomatous inflammatory infiltrate throughout the full thickness of the dermis and subcutaneous tissue. The granulomas had a lymphocytic corona (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Higher magnification revealed basophilic dot-like structures in the cytoplasm of many histiocytes (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) and Giemsa staining showed these structures to be cytoplasmic inclusion bodies without capsules.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">What Is Your Diagnosis?</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Chronic cutaneous leishmaniasis.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical Course</span><p id="par0035" class="elsevierStylePara elsevierViewall">Additional tests to rule out systemic involvement included a complete blood count, liver and kidney biochemistry, blood coagulation panel, chest radiograph, abdominal ultrasound, electrocardiogram, and serum anti–<span class="elsevierStyleItalic">Leishmania</span> immunoglobulins M and G, as well as urinary leishmanial antigen. Results were all normal or negative.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Further tests were carried out to rule out immune deficiency beyond that of advanced old age. Lymphocyte subpopulations, proteins, immunoglobulins, and serum immunofixation showed no significant abnormalities.</p><p id="par0045" class="elsevierStylePara elsevierViewall">With a confirmed diagnosis of cutaneous leishmaniasis, the extent and degree of progression of the lesion as well as the patient's overall health status led to the choice of miltefosine therapy. Pending hospital authorization of this off-label treatment, the patient was started on intramuscular meglumine antimoniate, which had to be withdrawn when she developed signs of heart failure.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Ultimately, the patient and her family decided to forgo any further treatment. No clinical recurrence has been observed so far.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Leishmaniasis is a zoonotic disease caused by a kinetoplastid protozoan of the <span class="elsevierStyleItalic">Leishmania</span> genus. This organism acts as an intracellular parasite of the mononuclear phagocytic system, and mammals are its reservoir hosts. In the Old World, leishmaniasis is transmitted by the bite of the female <span class="elsevierStyleItalic">Phlebotomus</span> sand fly. It is endemic to the Mediterranean basin. Clinical presentation may be cutaneous, mucocutaneous, or visceral. Manifestations vary according to the species involved (<span class="elsevierStyleItalic">L infantum</span> in the Mediterranean region) and to the patient's immune status prior to infection. Cutaneous signs range from the typical form, which consists of a centrally ulcerated papule, to extensive lesions or diffuse forms resulting from lymphatic or systemic spread.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Extensive skin manifestations, such as the present case, may necessitate differential diagnosis with lupus vulgaris, cutaneous sarcoidosis, or granuloma faciale. Diagnosis is confirmed either by the presence of amastigotes (Leishman-Donovan bodies) in histiocyte cytoplasm or by polymerase chain reaction, used particularly in cases where few amastigotes are present.</p><p id="par0065" class="elsevierStylePara elsevierViewall">These atypical, extensive cutaneous forms of leishmaniasis should be considered in immunodeficient as well as older patients. In recent years a number of cases of atypical cutaneous involvement have been described in patients undergoing treatment with anti–tumor necrosis factor biologic agents. Dermatologists should therefore consider the possibility of leishmaniasis in such cases even if clinical presentation does not otherwise suggest this diagnosis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">New therapeutic options for leishmaniasis are now available,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> including topical treatments, such as imiquimod<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and photodynamic therapy, and some systemic therapies, such as miltefosine. Miltefosine is as effective as standard antimonial treatments and is less toxic.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of Interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:3 [ "identificador" => "sec0010" "titulo" => "Physical Examination" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] ] ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical Course" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of Interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Torres Garcia Y, et al. Placa eritematodescamativa de lento crecimiento en la cara y el cuero cabelludo de una mujer anciana. Actas Dermosifiliogr. 2013;104:715–6.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1000 "Ancho" => 730 "Tamanyo" => 106347 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 448 "Ancho" => 736 "Tamanyo" => 143866 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, ×40.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 450 "Ancho" => 600 "Tamanyo" => 108432 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, ×400.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Leishmaniasis cutánea" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D. 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Santos" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "An Bras Dermatol" "fecha" => "2011" "volumen" => "86" "paginaInicial" => "497" "paginaFinal" => "506" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21738967" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Old world Leishmania infantum cutaneous leishmaniasis unresponsive to liposomal amphotericin B treated with topical imiquimod" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.A. Hervás" 1 => "A. Martín-Santiago" 2 => "D. Hervás" 3 => "E. Rojo" 4 => "A. Mena" 5 => "V. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 16 | 7 | 23 |
| 2024 Octubre | 87 | 43 | 130 |
| 2024 Septiembre | 65 | 24 | 89 |
| 2024 Agosto | 97 | 75 | 172 |
| 2024 Julio | 82 | 33 | 115 |
| 2024 Junio | 93 | 38 | 131 |
| 2024 Mayo | 69 | 38 | 107 |
| 2024 Abril | 80 | 32 | 112 |
| 2024 Marzo | 77 | 39 | 116 |
| 2024 Febrero | 100 | 34 | 134 |
| 2024 Enero | 77 | 36 | 113 |
| 2023 Diciembre | 73 | 36 | 109 |
| 2023 Noviembre | 75 | 35 | 110 |
| 2023 Octubre | 104 | 27 | 131 |
| 2023 Septiembre | 70 | 41 | 111 |
| 2023 Agosto | 43 | 25 | 68 |
| 2023 Julio | 70 | 43 | 113 |
| 2023 Junio | 69 | 21 | 90 |
| 2023 Mayo | 86 | 50 | 136 |
| 2023 Abril | 62 | 26 | 88 |
| 2023 Marzo | 93 | 20 | 113 |
| 2023 Febrero | 50 | 23 | 73 |
| 2023 Enero | 43 | 61 | 104 |
| 2022 Diciembre | 61 | 45 | 106 |
| 2022 Noviembre | 38 | 36 | 74 |
| 2022 Octubre | 22 | 19 | 41 |
| 2022 Septiembre | 24 | 33 | 57 |
| 2022 Agosto | 21 | 36 | 57 |
| 2022 Julio | 20 | 40 | 60 |
| 2022 Junio | 25 | 17 | 42 |
| 2022 Mayo | 39 | 41 | 80 |
| 2022 Abril | 61 | 31 | 92 |
| 2022 Marzo | 62 | 50 | 112 |
| 2022 Febrero | 50 | 30 | 80 |
| 2022 Enero | 80 | 35 | 115 |
| 2021 Diciembre | 41 | 45 | 86 |
| 2021 Noviembre | 41 | 42 | 83 |
| 2021 Octubre | 54 | 57 | 111 |
| 2021 Septiembre | 47 | 50 | 97 |
| 2021 Agosto | 58 | 30 | 88 |
| 2021 Julio | 38 | 33 | 71 |
| 2021 Junio | 43 | 35 | 78 |
| 2021 Mayo | 53 | 56 | 109 |
| 2021 Abril | 64 | 74 | 138 |
| 2021 Marzo | 76 | 33 | 109 |
| 2021 Febrero | 79 | 26 | 105 |
| 2021 Enero | 45 | 17 | 62 |
| 2020 Diciembre | 29 | 14 | 43 |
| 2020 Noviembre | 32 | 24 | 56 |
| 2020 Octubre | 25 | 7 | 32 |
| 2020 Septiembre | 26 | 15 | 41 |
| 2020 Agosto | 27 | 22 | 49 |
| 2020 Julio | 24 | 18 | 42 |
| 2020 Junio | 28 | 27 | 55 |
| 2020 Mayo | 16 | 16 | 32 |
| 2020 Abril | 27 | 21 | 48 |
| 2020 Marzo | 22 | 20 | 42 |
| 2020 Febrero | 3 | 4 | 7 |
| 2020 Enero | 0 | 2 | 2 |
| 2019 Diciembre | 4 | 11 | 15 |
| 2019 Noviembre | 0 | 1 | 1 |
| 2019 Octubre | 0 | 1 | 1 |
| 2019 Septiembre | 4 | 6 | 10 |
| 2019 Agosto | 0 | 1 | 1 |
| 2019 Julio | 0 | 5 | 5 |
| 2019 Junio | 2 | 6 | 8 |
| 2019 Mayo | 0 | 38 | 38 |
| 2019 Abril | 0 | 10 | 10 |
| 2019 Marzo | 2 | 7 | 9 |
| 2019 Febrero | 0 | 3 | 3 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Diciembre | 1 | 0 | 1 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Octubre | 2 | 0 | 2 |
| 2018 Septiembre | 4 | 0 | 4 |
| 2018 Marzo | 5 | 1 | 6 |
| 2018 Febrero | 35 | 7 | 42 |
| 2018 Enero | 35 | 3 | 38 |
| 2017 Diciembre | 35 | 6 | 41 |
| 2017 Noviembre | 24 | 4 | 28 |
| 2017 Octubre | 29 | 7 | 36 |
| 2017 Septiembre | 28 | 5 | 33 |
| 2017 Agosto | 47 | 7 | 54 |
| 2017 Julio | 50 | 7 | 57 |
| 2017 Junio | 57 | 19 | 76 |
| 2017 Mayo | 39 | 12 | 51 |
| 2017 Abril | 38 | 5 | 43 |
| 2017 Marzo | 27 | 12 | 39 |
| 2017 Febrero | 25 | 11 | 36 |
| 2017 Enero | 18 | 7 | 25 |
| 2016 Diciembre | 41 | 15 | 56 |
| 2016 Noviembre | 45 | 9 | 54 |
| 2016 Octubre | 41 | 17 | 58 |
| 2016 Septiembre | 53 | 3 | 56 |
| 2016 Agosto | 50 | 4 | 54 |
| 2016 Julio | 38 | 2 | 40 |
| 2016 Junio | 7 | 5 | 12 |
| 2016 Mayo | 6 | 8 | 14 |
| 2016 Abril | 7 | 3 | 10 |
| 2016 Marzo | 5 | 0 | 5 |
| 2016 Febrero | 8 | 1 | 9 |
| 2016 Enero | 8 | 1 | 9 |
| 2015 Diciembre | 18 | 3 | 21 |
| 2015 Noviembre | 4 | 0 | 4 |
| 2015 Octubre | 4 | 4 | 8 |
| 2015 Septiembre | 4 | 3 | 7 |
| 2015 Agosto | 3 | 4 | 7 |
| 2015 Julio | 40 | 2 | 42 |
| 2015 Junio | 35 | 1 | 36 |
| 2015 Mayo | 45 | 4 | 49 |
| 2015 Abril | 29 | 3 | 32 |
| 2015 Marzo | 25 | 4 | 29 |
| 2015 Febrero | 23 | 4 | 27 |
| 2015 Enero | 14 | 4 | 18 |
| 2014 Diciembre | 24 | 4 | 28 |
| 2014 Noviembre | 19 | 4 | 23 |
| 2014 Octubre | 26 | 5 | 31 |
| 2014 Septiembre | 21 | 2 | 23 |
| 2014 Agosto | 18 | 7 | 25 |
| 2014 Julio | 20 | 7 | 27 |
| 2014 Junio | 27 | 3 | 30 |
| 2014 Mayo | 25 | 7 | 32 |
| 2014 Abril | 26 | 6 | 32 |
| 2014 Marzo | 24 | 2 | 26 |
| 2014 Febrero | 15 | 4 | 19 |
| 2014 Enero | 20 | 2 | 22 |
| 2013 Diciembre | 16 | 3 | 19 |
| 2013 Noviembre | 1 | 2 | 3 |
| 2013 Octubre | 2 | 1 | 3 |
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