1. INTRODUCTION

Cutaneous leishmaniasis (CL) is the most common form of leishmaniasis [¹]. In 2020, more than 85% of world's new cases of CL occurred in 10 countries, including Algeria as well as Brazil, Peru and Colombia [²]. Ulcerative skin lesions characterize CL and occasionally nodular, psoriasiform, and verrucous lesions on exposed parts of the body [¹]. These lesions, mainly ulcers, leave life-long scars and serious disability and stigma [³]. Atypical lesions (such as erythematous volcanic ulcers and eczematous or erysipeloid lesions) may lead to a large panel of differential diagnoses [⁴].

We report a peculiar presentation of CL in an Algerian albino child, with a multiple cribriform ulcers and scars on the forehead.

2. CASE REPORT

An 11-year-old child boy with an unremarkable medical history apart from albinism was brought to our department for numerous tiny ulcers covering a large part of his forehead and glabella, persistent over the last 3 years despite many cycles of empiric antibiotic treatments. Physical examination revealed multiple asymptomatic, small and superficial ulcers with surrounding erythema and cribriform scars running from his middle forehead until the upper part of the nose (Figure 1). The underlying skin was infiltrated painless. His biochemical parameters were within normal limits, and there were mainly no signs of immunodeficiency syndrome. A history of staying in a leishmaniasis endemic area has been reported, and the diagnosis of CL has been confirmed by detecting Leishmania parasites in tissue specimens from skin ulcers via light-microscopic examination. Treatment by intramuscular injection of pentavalent antimony drugs at 10 mg/kg/day for a period of 15 consecutive days associated with oral prednisone 0.5 mg/kg/day for 5 days resulted in a clear regression and healing of ulcers within one month (Figure 2).

Figure 1: Multiple small and superficial ulcers, with surrounding erythema and cribriform scars, of the middle forehead, glabella and nose. 

Figure 2: Healing aspect of cutaneous leishmaniasis lesions one month after treatment initiation. 

3. DISCUSSION

The leishmaniases are considered as a spectrum ranging from benign forms represented by CL to mucocutaneous leishmaniasis and systemic visceral leishmaniasis. Further, CL encompasses other entities including localized CL, disseminated CL, recurrent (lupoid) CL and post Kala azar dermal leishmaniasis (Table 1). Different peculiar lesions of CL have been reported worldwide [⁴]. They may display various aspects, such as lupoid, eczematous, erysipeloid, verrucous, dry, zosteriform, paronychial, sporotrichoid, chancriform, annular and erythematous volcanic ulcers [⁵]. Our patient presented a rare, atypical form of CL with a number of superficial tiny ulcers and scars, and the affected area appeared as a “cribriform” plaque. Often, these atypical forms of CL are misdiagnosed as blastomycosis, sporotrichosis, diverse fungal skin infections, cutaneous anthrax, eczema, lepromatous leprosy, tuberculosis, Mycobacterium marinum infections, basal and squamous cell carcinomas, and even infected insect bites [⁴]; and this would result in delayed diagnosis and treatment, as in our case. The reason for this pleomorphism is still unclear, but it might reflect an underlying immune disturbance; and variations in parasite virulence and host factors have been hypothesized to modulate the CL presentation [⁴]. Our patient depicts only albinism, which is not an immune deficiency by itself.

Table 1: Classification of cutaneous leishmaniasis (adaptation of the classifications of Akilov et al [⁶]). 

Treatment of CL differs according to infecting species, extent, location and progression of the disease. Usually, for limited infection when one or a few small lesions are present (excluding periorificial areas or over a joint) topical treatment could be proposed as the sole therapy. However, systemic therapy (mainly antimony drugs) should be used for more extensive lesions (Table 2).

Table 2: Treatments for Cutaneous Leishmaniasis in adults and Children [⁷, ⁸, ⁹]. 

4. CONCLUSIONS

We report an exceptional clinical observation of CL with a multiple cribriform ulcers and scars on the forehead of albino child. Although, a large number of atypical morphological forms of CL have already been described, such presentation has not been reported in the literature before as far as we know. Thus, the healthcare professionals should perform the best diagnostic and treatment methods to lessen misdiagnoses and control disease progression. Physicians, especially those practicing in CL endemic areas like the Americas and the Mediterranean basin, should bear in mind that the disease may present with various clinical features and even unexpected aspects.