Leishmaniasis is a parasitic infection caused by species leishmaniae, which can produce two types of manifestations: visceral and cutaneous. In south America cutaneous leishmaniasis is more common than visceral leishmaniasis. A case of primary cutaneous leishmaniasis from Bolivia is presented for its rarity. The patient of our case showed an ulcerated lesion of the knee. Montenegro's intradermal test was positive. Giemsa-stained touch preparation of the skin biopsy revealed amastigotes inside macrophages, consistent with leishmaniasis. The patient was treated with meglumine antimoniate intramuscular (20 mg of Sb+/kg/day) three weeks, with complete cicatrization of the lesion.Facultad de Ciencias Exacta

Bava, Amadeo Javier

Rossi, María Laura

Seley, Celeste

Troncoso, Alcides

Asian Pacific Journal of Tropical Medicine

SEDICI - Repositorio de la UNLP

330 Asian Pacific Journal of Tropical Medicine (2010)330-331
ELSEVIER
Contents lists available at ScienceDirect
Asian Pacific Journal of Tropical Medicine
journal homepage:www.elsevier.com/locate/apjtm
Document heading
Leishmaniasis in the knee area
Bava Aniadeo Javier1, Rossi Maria Laura , Seley Celeste , Troncoso Alcides+
1 Department of Micology, La Plata University
" Department of Microbiology, Parasitolog y and Infectious Diseases. Sch ool of Medicine. Buenos Aires Universit y
ARTICLE INFO ABSTRACT
Article history:
Received 27 February 2010
Received in revised form 16 March 2010
Accepted 29 March 2010
Available online 10 April
Keywords:
Cutaneous leishmaniasis
Skin ulcers
Leishmania
Leishmaniasis is a parasitic infection caused by species leishmaniae, which can produce two 
types of manifestations: visceral and cutaneous. In south America cutaneous leishmaniasis is 
more common than visceral leishmaniasis. A case of primary cutaneous leishmaniasis from 
Bolivia is presented for its rarity. The patient of our case showed an ulcerated lesion of the knee. 
Montenegro's intradermal test was positive. Giemsa-stained touch preparation of the skin biopsy 
revealed amastigotes inside macrophages, consistent with leishmaniasis. The patient was treated 
with meglumine antimoniate intramuscular (20 mg of Sb+/kg/day) three weeks, with complete 
cicatrization of the lesion.
1.Introduction
Leishmaniasis designates a human disorder produced by 
protozoan parasites of the genus Leishmania. There are four 
major clinical types of this infection: cutaneous, diffuse 
cutaneous, mucocutaneous, and visceralji]. The clinical 
manifestations of leishmaniasis depend on the interaction 
between the characteristic virulence of the species and 
the host's immune response^]. The cutaneous form of the 
disease, is one of the most important causes of chronic 
ulcerative skin lesions. Cutaneous leishmaniasis (CL) is 
characterized by the development of single or multiple 
localized lesions on exposed areas of skin that typically 
ulcerate and generally heal spontaneously within 3-6 
monthsji]. We present one case of cutaneous leishmaniasis 
in the knee area, a very unusual localization.
2. Case report
A man of 52 years old silver mine worker from Cerro 
Rico, Potosi Municipality, Bolivia, presented with a two- 
months history of an ulcerative lesion over the knee. At 
physical examination, an ulcerated lesion of 8 cmxl3 cm 
in diameter, with an indurated base and raised, infiltrative 
borders was noted (Figure 1). The rest of the skin was 
normal. There was no history of pain and tenderness. He 
had no history of fever, weight loss or weakness. Clinical
* Corresponding author: Dr. Alcides Troncoso, M.D., Ph.D.,Department of Infectious 
Diseases, Bartolome Mitre 1906, CP: 1039—Buenos Aires, Argentina.
E-mail: microbiologiayparasitologia@yahoo.com.ar 
examination showed no significant abnormality. No 
regional lymphadenopathy or clinical signs of visceral 
involvement were detected. On investigations, chest X-ray 
did not show any abnormality. A complete blood cell count 
and blood chemistries gave results within normal limits. 
Leishmanin skin test was positive: indurated papule, 22 
mm diameter. An excision biopsy of the lesion was done 
and routine histopathological examination was done. 
Histopathological study showed ulceration of epidermis and 
a diffuse inflammatory infiltrate in the dermis composed 
of lymphocytes, histiocytes, plasma cells and giant cells 
with granuloma formation and presence of Leishmania 
amastigotes. Culture was attempted in RE III medium 
but was unsuccessful because of overgrowth of yeast. The 
diagnosis of cutaneous leishmaniasis was made. The patient 
was treated with meglumine antimoniate intramuscular (20 
mg of Sb+/kg/day) during three weeks and with fully healed 
lesion at the end of therapy. The patient tolerated the 
medication well and did not require hospitalization. 2 years 
followup showed no evidence exists of cutaneous, mucous, 
or visceral involvement.
3. Discussion
Leishmania is a protozoa that may infect the skin, mucous, 
and viscera. The geographical distribution of CL is mainly 
determined by the sandfly vectors. CL is an infectious 
disease caused by protozoa of the gender Leishmania, 
transmitted by stings of female insects of the gender 
Phlebotomus in the old world and Lutzomyia in the new 
world. The old world cutaneous leishmania comprise three 
species _ Leishmania tropica, Leishmania major and 
Bava Amadeo Javier et al./Asian Pacific Journal of Tropical Medicine (2010)330-331 331
Leishmania aethiopica. The areas of disease are Middle 
East, Northern Africa, Sub Saharan Africa, East Asia and 
Southern Europe. The species of cutaneous leishmaniae 
of the new world are more numerous and more difficult 
to classify. They produce disease that are more chronic 
than old world. The species are-Leishmania braziliensis, 
Leishmania mexica, Leishmania guyanensis, Leishmania 
panamensis, Leishmania peruviana. The areas of disease 
are South America and the Carribean Islands where 
the preferred term is "Tegumentary" or mucocutaneous 
leishmaniasis. Morphology and histology of the cutaneous 
leishmania of the old and new world are similar^].
Figure 1. Clinical aspects of the lesion when the patient sough 
treatment at the University Hospital.
In the last years, an increment of the number of cutaneous 
leishmaniasis in in the poor working conditions of Cerro 
Rico in Potosi, Bolivia, have been observed. In this patient, 
the clinical characteristics of the lesion suggested CL. 
After biopsy and histopathological study, the diagnosis of 
leishmaniasis was confirmed. The patient informed the habit 
of sleeping undressed and outside the house. There are few 
published cases of leishmaniasis located in the knee area, 
settling down in most of them that the lesions are due to 
direct inoculation of the parasitelh. Some authors suggest 
that the genital localization can result in the possible blood 
dissemination. The diagnosis of cutaneous leishmaniae is 
usually made on clinical grounds like endemic area, clinical 
presentation and origin of the patientM.
While low-grade silver is still extracted from the Cerro 
Rico mines, zinc is now the most profitable metal for the 
miners of Potosi. The silver "boom" days gradually came to 
an end in the early I SOON as the mines became depleted. 
However, as many as 8 000 miners still try to earn a living 
in the Cerro Rico mines, also known as Cerro Potosi. 
The miners, many of whom are local Quechua-speaking 
Indians, now work in small co-operatives. They work, albeit 
collectively for themselves. While the days of slavery have 
thankfully come to an end, conditions and techniques within 
the mines of Cerro Rico have changed little. The shaft 
network is primitive, poorly lit and inadequately ventilated, 
with temperatures often reaching 48 °( UJ.
Where power cables are present, they are often poorly 
maintained and often exposed. Elevators are not installed 
for moving between levels. The Bolivian miners squeeze 
through small crawl spaces and climb old wooden ladders to 
access the deep-cut extremes of the Potosi mines. Within 
the cramped depths of the Cerro Rico mine the workers 
hammer iron rods into the rock face, progressing slowly 
before removing the rod and sliding dynamite into the newly 
formed hole. Retreating to a supposedly safe distance, 
fuses are then used to detonate the explosives. This process 
creates a newly exposed area in which to mine!5].
In areas where leishmaniasis is endemic such as in the south 
America countries, even in the absence of an appropriate 
history of exposure to Leishmania, such a possibility may 
be kept in mind for any ulcerated lesionKJ. The definitive 
diagnosis depends on demonstrating either amastigotes 
in tissue or promastigotes in culture!7]. The diagnosis in our 
case was based on the presence of amastigotes in the stains 
with Giemsa technique and hematoxylin and eosin, which 
may quickly yield a diagnosis in some patients. Differential 
diagnosis for CL includes secondarily infected insect bite, 
sporotrichosis, or more rarely cutaneous tuberculosis; early 
detection of the infection is necessary in order to start 
effective treatment and prevent more serious complications^]. 
The reported case presented an unusual localization of 
cutaneous leishmaniasis, which should be outlined mainly 
in those patients coming from endemic areas, being the key 
to practice necessary complementary exams to confirm the 
diagnosis!?!.
Conflict of interest statement
We declare that we have no conflict of interest.
Acknowledgments
We appreciate invaluable technical assistance provided by 
Luciana Rivas.
References
[lJLucas S. Pathology of tropical infections. In : McGee JO'D, Isaacson 
PG, Wright NA editors. Oxford textbook of pathology. 1st ed. New 
York: Oxford University Press; 1992, p. 2189-254.
[2] Chatterjee KD. Subphylum sarcomastigophora. In: Chatterjee KD. 
Parasitology, protozoology and helminthology in relation to clinical 
medicine. 12th ed. Calcutta: Chatterjee Medical Publishers; 1980, 
p. 14-69.
[3] Hepburn NC. Cutaneous leishmaniasis: an overview. J Postgrad 
Med 2003; 49:50-4.
[4] Jacob M, George R, George S, Kuruvillas S. Diseases caused by 
parasitic worms and protozoa. In: Valia RG, Valia AR. Textbook and 
Atlas of dermatology. 1st ed. Bombay: Bhalani Publishing House; 
1994, p.311-50.
[5] Wismath Ryder E, Troncoso A, Seley C. Community participation 
in dengue prevention and control-an urban neglected tropical disease. 
La Prensa Medica Argentina 2009; 185-95.
[5] Gutieirez Y, Lichtenberg FV. Protozoal diseases. In: Damjanov L, 
Linder J. Anderson's pathology. 10th ed. St Louis: Mosby-year book, 
Inc.; 1996, p. 985-1011.
[6] Bennan J. Recent developments in leishmaniasis: epidemiology, 
diagnosis, and treatment. Curr Infect Dis Resp 2005; 7: 33-8.
[7] Giudice PD, Marty P, Lacour JP, Perin C, Pratlog F. Cutaneous 
Leishmaniasis due to Leishmania infantum. Arch Dermatol 1998; 134: 
193-98.
[8] Maroli M, Khoury C. Prevention and control of leishmaniasis 
vectors: current approaches. Parasitology 2004; 46: 211-5.
[9] Charif Chefchaouni M, Lamrani R, Benjelloune A, El Lyacoubi M, 
Berraho A. Cutaneous leishmaniasis of the lid. J Fr Oph thalmol 2002; 
25: 522-6.


English

Leishmaniasis in the knee area

Servicio de Difusión de la Creación Intelectual

330 Asian Pacific Journal of Tropical Medicine (2010)330-331ELSEVIERContents lists available at ScienceDirectAsian Pacific Journal of Tropical Medicinejournal homepage:www.elsevier.com/locate/apjtmDocument headingLeishmaniasis in the knee areaBava Aniadeo Javier1, Rossi Maria Laura , Seley Celeste , Troncoso Alcides+1 Department of Micology, La Plata University" Department of Microbiology, Parasitolog y and Infectious Diseases. Sch ool of Medicine. Buenos Aires Universit yARTICLE INFO ABSTRACTArticle history:Received 27 February 2010Received in revised form 16 March 2010Accepted 29 March 2010Available online 10 AprilKeywords:Cutaneous leishmaniasisSkin ulcersLeishmaniaLeishmaniasis is a parasitic infection caused by species leishmaniae, which can produce two types of manifestations: visceral and cutaneous. In south America cutaneous leishmaniasis is more common than visceral leishmaniasis. A case of primary cutaneous leishmaniasis from Bolivia is presented for its rarity. The patient of our case showed an ulcerated lesion of the knee. Montenegro's intradermal test was positive. Giemsa-stained touch preparation of the skin biopsy revealed amastigotes inside macrophages, consistent with leishmaniasis. The patient was treated with meglumine antimoniate intramuscular (20 mg of Sb+/kg/day) three weeks, with complete cicatrization of the lesion.1.IntroductionLeishmaniasis designates a human disorder produced by protozoan parasites of the genus Leishmania. There are four major clinical types of this infection: cutaneous, diffuse cutaneous, mucocutaneous, and visceralji]. The clinical manifestations of leishmaniasis depend on the interaction between the characteristic virulence of the species and the host's immune response^]. The cutaneous form of the disease, is one of the most important causes of chronic ulcerative skin lesions. Cutaneous leishmaniasis (CL) is characterized by the development of single or multiple localized lesions on exposed areas of skin that typically ulcerate and generally heal spontaneously within 3-6 monthsji]. We present one case of cutaneous leishmaniasis in the knee area, a very unusual localization.2. Case reportA man of 52 years old silver mine worker from Cerro Rico, Potosi Municipality, Bolivia, presented with a two- months history of an ulcerative lesion over the knee. At physical examination, an ulcerated lesion of 8 cmxl3 cm in diameter, with an indurated base and raised, infiltrative borders was noted (Figure 1). The rest of the skin was normal. There was no history of pain and tenderness. He had no history of fever, weight loss or weakness. Clinical* Corresponding author: Dr. Alcides Troncoso, M.D., Ph.D.,Department of Infectious Diseases, Bartolome Mitre 1906, CP: 1039—Buenos Aires, Argentina.E-mail: microbiologiayparasitologia@yahoo.com.ar examination showed no significant abnormality. No regional lymphadenopathy or clinical signs of visceral involvement were detected. On investigations, chest X-ray did not show any abnormality. A complete blood cell count and blood chemistries gave results within normal limits. Leishmanin skin test was positive: indurated papule, 22 mm diameter. An excision biopsy of the lesion was done and routine histopathological examination was done. Histopathological study showed ulceration of epidermis and a diffuse inflammatory infiltrate in the dermis composed of lymphocytes, histiocytes, plasma cells and giant cells with granuloma formation and presence of Leishmania amastigotes. Culture was attempted in RE III medium but was unsuccessful because of overgrowth of yeast. The diagnosis of cutaneous leishmaniasis was made. The patient was treated with meglumine antimoniate intramuscular (20 mg of Sb+/kg/day) during three weeks and with fully healed lesion at the end of therapy. The patient tolerated the medication well and did not require hospitalization. 2 years followup showed no evidence exists of cutaneous, mucous, or visceral involvement.3. DiscussionLeishmania is a protozoa that may infect the skin, mucous, and viscera. The geographical distribution of CL is mainly determined by the sandfly vectors. CL is an infectious disease caused by protozoa of the gender Leishmania, transmitted by stings of female insects of the gender Phlebotomus in the old world and Lutzomyia in the new world. The old world cutaneous leishmania comprise three species _ Leishmania tropica, Leishmania major and Bava Amadeo Javier et al./Asian Pacific Journal of Tropical Medicine (2010)330-331 331Leishmania aethiopica. The areas of disease are Middle East, Northern Africa, Sub Saharan Africa, East Asia and Southern Europe. The species of cutaneous leishmaniae of the new world are more numerous and more difficult to classify. They produce disease that are more chronic than old world. The species are-Leishmania braziliensis, Leishmania mexica, Leishmania guyanensis, Leishmania panamensis, Leishmania peruviana. The areas of disease are South America and the Carribean Islands where the preferred term is "Tegumentary" or mucocutaneous leishmaniasis. Morphology and histology of the cutaneous leishmania of the old and new world are similar^].Figure 1. Clinical aspects of the lesion when the patient sough treatment at the University Hospital.In the last years, an increment of the number of cutaneous leishmaniasis in in the poor working conditions of Cerro Rico in Potosi, Bolivia, have been observed. In this patient, the clinical characteristics of the lesion suggested CL. After biopsy and histopathological study, the diagnosis of leishmaniasis was confirmed. The patient informed the habit of sleeping undressed and outside the house. There are few published cases of leishmaniasis located in the knee area, settling down in most of them that the lesions are due to direct inoculation of the parasitelh. Some authors suggest that the genital localization can result in the possible blood dissemination. The diagnosis of cutaneous leishmaniae is usually made on clinical grounds like endemic area, clinical presentation and origin of the patientM.While low-grade silver is still extracted from the Cerro Rico mines, zinc is now the most profitable metal for the miners of Potosi. The silver "boom" days gradually came to an end in the early I SOON as the mines became depleted. However, as many as 8 000 miners still try to earn a living in the Cerro Rico mines, also known as Cerro Potosi. The miners, many of whom are local Quechua-speaking Indians, now work in small co-operatives. They work, albeit collectively for themselves. While the days of slavery have thankfully come to an end, conditions and techniques within the mines of Cerro Rico have changed little. The shaft network is primitive, poorly lit and inadequately ventilated, with temperatures often reaching 48 °( UJ.Where power cables are present, they are often poorly maintained and often exposed. Elevators are not installed for moving between levels. The Bolivian miners squeeze through small crawl spaces and climb old wooden ladders to access the deep-cut extremes of the Potosi mines. Within the cramped depths of the Cerro Rico mine the workers hammer iron rods into the rock face, progressing slowly before removing the rod and sliding dynamite into the newly formed hole. Retreating to a supposedly safe distance, fuses are then used to detonate the explosives. This process creates a newly exposed area in which to mine!5].In areas where leishmaniasis is endemic such as in the south America countries, even in the absence of an appropriate history of exposure to Leishmania, such a possibility may be kept in mind for any ulcerated lesionKJ. The definitive diagnosis depends on demonstrating either amastigotes in tissue or promastigotes in culture!7]. The diagnosis in our case was based on the presence of amastigotes in the stains with Giemsa technique and hematoxylin and eosin, which may quickly yield a diagnosis in some patients. Differential diagnosis for CL includes secondarily infected insect bite, sporotrichosis, or more rarely cutaneous tuberculosis; early detection of the infection is necessary in order to start effective treatment and prevent more serious complications^]. The reported case presented an unusual localization of cutaneous leishmaniasis, which should be outlined mainly in those patients coming from endemic areas, being the key to practice necessary complementary exams to confirm the diagnosis!?!.Conflict of interest statementWe declare that we have no conflict of interest.AcknowledgmentsWe appreciate invaluable technical assistance provided by Luciana Rivas.References[lJLucas S. Pathology of tropical infections. In : McGee JO'D, Isaacson PG, Wright NA editors. Oxford textbook of pathology. 1st ed. New York: Oxford University Press; 1992, p. 2189-254.[2] Chatterjee KD. Subphylum sarcomastigophora. In: Chatterjee KD. Parasitology, protozoology and helminthology in relation to clinical medicine. 12th ed. Calcutta: Chatterjee Medical Publishers; 1980, p. 14-69.[3] Hepburn NC. Cutaneous leishmaniasis: an overview. J Postgrad Med 2003; 49:50-4.[4] Jacob M, George R, George S, Kuruvillas S. Diseases caused by parasitic worms and protozoa. In: Valia RG, Valia AR. Textbook and Atlas of dermatology. 1st ed. Bombay: Bhalani Publishing House; 1994, p.311-50.[5] Wismath Ryder E, Troncoso A, Seley C. Community participation in dengue prevention and control-an urban neglected tropical disease. La Prensa Medica Argentina 2009; 185-95.[5] Gutieirez Y, Lichtenberg FV. Protozoal diseases. In: Damjanov L, Linder J. Anderson's pathology. 10th ed. St Louis: Mosby-year book, Inc.; 1996, p. 985-1011.[6] Bennan J. Recent developments in leishmaniasis: epidemiology, diagnosis, and treatment. Curr Infect Dis Resp 2005; 7: 33-8.[7] Giudice PD, Marty P, Lacour JP, Perin C, Pratlog F. Cutaneous Leishmaniasis due to Leishmania infantum. Arch Dermatol 1998; 134: 193-98.[8] Maroli M, Khoury C. Prevention and control of leishmaniasis vectors: current approaches. Parasitology 2004; 46: 211-5.[9] Charif Chefchaouni M, Lamrani R, Benjelloune A, El Lyacoubi M, Berraho A. Cutaneous leishmaniasis of the lid. J Fr Oph thalmol 2002; 25: 522-6.

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Leishmaniasis in the knee area

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