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erysipeloid presentation&#44; and the corresponding ultrasound findings&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case 1</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 62-year-old man with a personal history of hepatic porphyria cutanea was seen for a lesion covering a large portion of the external aspect of the shoulder and upper left arm&#46; The lesion had appeared 2 months earlier and was occasionally suppurative&#46; The patient had been previously treated for suspected cellulitis with multiple oral antibiotics&#44; without improvement&#46; Physical examination revealed an indurated&#44; erythematous plaque &#40;9<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>cm&#41; with poorly defined borders that was hot to the touch &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; Histology revealed non-necrotizing granulomatous dermatitis and the presence of <span class="elsevierStyleItalic">Leishmania</span> bodies within the cytoplasm of the histiocytes&#46; Skin ultrasound &#40;SonoScape&#44; 15-MHz linear probe&#41; was performed to evaluate the extent of the lesion and showed diffuse thickening of the dermis in the affected area &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; Because of the lesion&#39;s large size&#44; the patient was treated with intravenous amphotericin B &#40;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#41; for 3 days &#40;total dose&#44; 15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41;&#46; The lesion resolved in response to treatment &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#44; as confirmed by subsequent ultrasound &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 66-year-old man with a personal history of diabetes mellitus type 2 and dyslipidemia was referred from the otorhinolaryngology department with an asymptomatic lesion on the right pinna that had appeared 5 months earlier&#46; He reported no previous trauma or insect bites in the affected location&#46; The patient had been diagnosed with erysipela&#44; for which he was treated with several oral and topical antibiotics&#44; with no improvement&#46; Physical examination revealed diffuse erythema on the right pinna&#46; On the earlobe and antitragus the erythema was more pronounced and was accompanied by marked thickening &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Histology revealed similar findings to those described for Case 1&#46; The result of a PCR test for <span class="elsevierStyleItalic">Leishmania</span> DNA was positive&#46; Ultrasound &#40;SonoScape&#44; 15-MHz linear probe&#41; revealed an unencapsulated&#44; hypoechoic structure in the superficial dermis that was well-delimited near the surface and less so at deeper levels&#44; and exhibited increased low-resistance flow on Doppler imaging &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; The lesion resolved after treatment for 4 weeks with weekly infiltrations of intralesional meglumine antimoniate &#40;injected subdermally until a wheal formed&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C and D&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Examination of both patients after 6 months revealed no signs of lesion recurrence or reactivation&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Leishmaniasis is a group of diseases caused by infection with any of over 20 protozoan species of the genus <span class="elsevierStyleItalic">Leishmania</span>&#44; and is transmitted by the bite of insects of the genera <span class="elsevierStyleItalic">Phlebotomus</span> and <span class="elsevierStyleItalic">Lutzomyia</span> in the Old World and New World&#44; respectively&#46; The most common reservoirs are domestic mammals such as the dog&#44; cat&#44; rat&#44; hare&#44; and rabbit&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">CL has many different presentations&#44; and recent years have seen an increase in atypical forms&#46; The clinical presentation of leishmaniasis depends&#44; among other factors&#44; on the species involved and the immune response of the host&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2&#44;4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In a series published by Bari and Rahman&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> up to 5&#46;7&#37; of the 718 cases described were considered unusual forms of CL&#46; These included lupoid&#44; sporotrichoid&#44; paronychial&#44; erysipeloid&#44; palpebral&#44; psoriasiform&#44; mycetoma-like&#44; chancriform&#44; scar&#44; zosteriform&#44; palmar&#47;plantar&#44; verrucous&#44; and eczematous CL&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;4</span></a><span class="elsevierStyleItalic">Lutzomyia mexicana</span> causes a form of CL that is uncommon in the Old World but is transmitted by <span class="elsevierStyleItalic">Lutzomyia olmeca</span> in the New World&#44; where it typically affects rubber workers and in over 50&#37; of cases results in the formation of an ulcerated lesion on the pinna known as a <span class="elsevierStyleItalic">chiclero</span> ulcer&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2&#44;5&#44;6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Occasionally these atypical presentations can simulate other infectious or inflammatory skin conditions&#46; The erysipeloid form&#44; of which few cases are described in the literature&#44; is characterized by poorly defined erythematous plaques that resemble those seen in erysipelas or cellulitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;7&#44;8</span></a> In our patients&#44; who had erythematous and indurated plaques on the shoulder and pinna&#44; respectively&#44; the initial diagnostic suspicions were cellulitis and erysipelas&#44; respectively&#46; Both patients responded poorly to subsequent antibiotic treatment&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Although suspected CL is often diagnosed clinically&#44; diagnosis should be confirmed using microbiological &#40;<span class="elsevierStyleItalic">Leishmania</span> culture in special media&#44; direct examination&#44; PCR of tissue and&#47;or blood samples&#41; and&#47;or histological techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Skin ultrasound is a fast&#44; safe&#44; and effective technique&#44; and is increasingly used in dermatology&#46; We have found no published descriptions of ultrasound findings in CL patients&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In our patients&#44; ultrasound revealed diffuse thickening of the dermis in the first case&#44; accompanied in the second case by a poorly defined and vascularized structure in the superficial dermis and an increase in the thickness of the dermis&#46; These alterations resolved after treatment&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Although the ultrasound findings were nonspecific&#44; ultrasound served as a useful additional diagnostic tool to identify dermal alterations and increased Doppler flow&#46; More importantly&#44; in both cases it allowed us to monitor the treatment response&#44; and revealed resolution of the structural alterations in the subepidermal tissue&#46; This would not have been possible by visual examination&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">We describe 2 cases of erysipeloid CL&#46; CL should be included in the differential diagnosis of lesions suggestive of erysipelas or cellulitis that do not respond to conventional antibiotics&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">We wish to highlight the role of ultrasound in these cases not only as an additional diagnostic technique&#44; but also as a means of monitoring treatment response&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of Interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case and Research Letter
An Unusual Presentation of Cutaneous Leishmaniasis: The Role of Skin Ultrasound
Leishmaniasis cutánea de presentación inusual. Papel de la ecografía cutánea
E. Rojas Mora
Autor para correspondencia
esromo16@gmail.com

Corresponding author.
, A. Garrido Ríos, B. Echeverría García, J. Borbujo
Servicio de Dermatología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cutaneous leishmaniasis &#40;CL&#41; manifests as a papule or nodule that forms in response to the bite of mosquitoes that carries this parasitosis&#46; These lesions tend to grow to form a well-defined plaque with a raised violaceous border that may ulcerate&#44; leading to subsequent formation of a crust&#46; Atypical presentations of CL are increasingly common&#44; and pose a diagnostic challenge&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Diagnosis is based on histological and microbiological findings &#40;ie&#44; a positive result in polymerase chain reaction &#91;PCR&#93; analysis of blood or tissue&#41;&#46; However&#44; skin ultrasound can be a useful complementary technique for CL diagnosis and a tool to monitor treatment response in CL patients&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We describe 2 cases of CL with an unusual&#44; erysipeloid presentation&#44; and the corresponding ultrasound findings&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case 1</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 62-year-old man with a personal history of hepatic porphyria cutanea was seen for a lesion covering a large portion of the external aspect of the shoulder and upper left arm&#46; The lesion had appeared 2 months earlier and was occasionally suppurative&#46; The patient had been previously treated for suspected cellulitis with multiple oral antibiotics&#44; without improvement&#46; Physical examination revealed an indurated&#44; erythematous plaque &#40;9<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>cm&#41; with poorly defined borders that was hot to the touch &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; Histology revealed non-necrotizing granulomatous dermatitis and the presence of <span class="elsevierStyleItalic">Leishmania</span> bodies within the cytoplasm of the histiocytes&#46; Skin ultrasound &#40;SonoScape&#44; 15-MHz linear probe&#41; was performed to evaluate the extent of the lesion and showed diffuse thickening of the dermis in the affected area &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; Because of the lesion&#39;s large size&#44; the patient was treated with intravenous amphotericin B &#40;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#41; for 3 days &#40;total dose&#44; 15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41;&#46; The lesion resolved in response to treatment &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#44; as confirmed by subsequent ultrasound &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 66-year-old man with a personal history of diabetes mellitus type 2 and dyslipidemia was referred from the otorhinolaryngology department with an asymptomatic lesion on the right pinna that had appeared 5 months earlier&#46; He reported no previous trauma or insect bites in the affected location&#46; The patient had been diagnosed with erysipela&#44; for which he was treated with several oral and topical antibiotics&#44; with no improvement&#46; Physical examination revealed diffuse erythema on the right pinna&#46; On the earlobe and antitragus the erythema was more pronounced and was accompanied by marked thickening &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Histology revealed similar findings to those described for Case 1&#46; The result of a PCR test for <span class="elsevierStyleItalic">Leishmania</span> DNA was positive&#46; Ultrasound &#40;SonoScape&#44; 15-MHz linear probe&#41; revealed an unencapsulated&#44; hypoechoic structure in the superficial dermis that was well-delimited near the surface and less so at deeper levels&#44; and exhibited increased low-resistance flow on Doppler imaging &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; The lesion resolved after treatment for 4 weeks with weekly infiltrations of intralesional meglumine antimoniate &#40;injected subdermally until a wheal formed&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C and D&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Examination of both patients after 6 months revealed no signs of lesion recurrence or reactivation&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Leishmaniasis is a group of diseases caused by infection with any of over 20 protozoan species of the genus <span class="elsevierStyleItalic">Leishmania</span>&#44; and is transmitted by the bite of insects of the genera <span class="elsevierStyleItalic">Phlebotomus</span> and <span class="elsevierStyleItalic">Lutzomyia</span> in the Old World and New World&#44; respectively&#46; The most common reservoirs are domestic mammals such as the dog&#44; cat&#44; rat&#44; hare&#44; and rabbit&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">CL has many different presentations&#44; and recent years have seen an increase in atypical forms&#46; The clinical presentation of leishmaniasis depends&#44; among other factors&#44; on the species involved and the immune response of the host&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2&#44;4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In a series published by Bari and Rahman&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> up to 5&#46;7&#37; of the 718 cases described were considered unusual forms of CL&#46; These included lupoid&#44; sporotrichoid&#44; paronychial&#44; erysipeloid&#44; palpebral&#44; psoriasiform&#44; mycetoma-like&#44; chancriform&#44; scar&#44; zosteriform&#44; palmar&#47;plantar&#44; verrucous&#44; and eczematous CL&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;4</span></a><span class="elsevierStyleItalic">Lutzomyia mexicana</span> causes a form of CL that is uncommon in the Old World but is transmitted by <span class="elsevierStyleItalic">Lutzomyia olmeca</span> in the New World&#44; where it typically affects rubber workers and in over 50&#37; of cases results in the formation of an ulcerated lesion on the pinna known as a <span class="elsevierStyleItalic">chiclero</span> ulcer&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2&#44;5&#44;6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Occasionally these atypical presentations can simulate other infectious or inflammatory skin conditions&#46; The erysipeloid form&#44; of which few cases are described in the literature&#44; is characterized by poorly defined erythematous plaques that resemble those seen in erysipelas or cellulitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;7&#44;8</span></a> In our patients&#44; who had erythematous and indurated plaques on the shoulder and pinna&#44; respectively&#44; the initial diagnostic suspicions were cellulitis and erysipelas&#44; respectively&#46; Both patients responded poorly to subsequent antibiotic treatment&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Although suspected CL is often diagnosed clinically&#44; diagnosis should be confirmed using microbiological &#40;<span class="elsevierStyleItalic">Leishmania</span> culture in special media&#44; direct examination&#44; PCR of tissue and&#47;or blood samples&#41; and&#47;or histological techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Skin ultrasound is a fast&#44; safe&#44; and effective technique&#44; and is increasingly used in dermatology&#46; We have found no published descriptions of ultrasound findings in CL patients&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In our patients&#44; ultrasound revealed diffuse thickening of the dermis in the first case&#44; accompanied in the second case by a poorly defined and vascularized structure in the superficial dermis and an increase in the thickness of the dermis&#46; These alterations resolved after treatment&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Although the ultrasound findings were nonspecific&#44; ultrasound served as a useful additional diagnostic tool to identify dermal alterations and increased Doppler flow&#46; More importantly&#44; in both cases it allowed us to monitor the treatment response&#44; and revealed resolution of the structural alterations in the subepidermal tissue&#46; This would not have been possible by visual examination&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">We describe 2 cases of erysipeloid CL&#46; CL should be included in the differential diagnosis of lesions suggestive of erysipelas or cellulitis that do not respond to conventional antibiotics&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">We wish to highlight the role of ultrasound in these cases not only as an additional diagnostic technique&#44; but also as a means of monitoring treatment response&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of Interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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