Diagnosis at first sight
Unusual genital lesion mimicking squamous cell carcinoma: A diagnostic challenge
Lesión genital inusual simulando carcinoma epidermoide: un desafío diagnóstico
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Haematoxylin-eosin. Arrows indicate the presence of amastigotes of <span class="elsevierStyleItalic">Leishmania</span>.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of a 75-year-old male, resident in a rural area in southern Andalusia, who came to the Dermatology department with a six-month history of a persistent painless ulcer on his penis. He denied risky sexual behaviour. He had no fever, weight loss or other systemic symptoms. After the ulcer appeared, he was prescribed various topical treatments, including corticosteroids, antifungals and antibiotics for 6-8 weeks, without improvement. His medical history included a circumcision performed by the Urology department in 2021 due to lesions suggestive of candidiasis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">On physical examination, a 3<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1-cm ulcer with raised edges was seen on the dorsal aspect of the patient’s penis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). No inguinal lymphadenopathy could be palpated. No other skin or mucosal lesions were detected. Blood tests were performed, which revealed monoclonal IgM lambda hypergammaglobulinaemia. Liver function tests were normal. VDRL, HIV, HCV and HSV serology tests were negative. There was evidence of a past HBV infection. As squamous cell carcinoma was initially suspected, a biopsy was performed.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Clinical course and diagnosis</span><p id="par0015" class="elsevierStylePara elsevierViewall">Histopathological analysis confirmed ulcerated lymphohistiocytic dermatitis of the foreskin (balanoposthitis) with a marked plasma cell component, secondary to active <span class="elsevierStyleItalic">Leishmania</span> infection (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). PCR of the leishmania genome was positive. To type the <span class="elsevierStyleItalic">Leishmania</span> species (most likely <span class="elsevierStyleItalic">infantum</span>), it was necessary to extract DNA from the remaining sample and send it to a reference centre. Given the urgency of starting treatment, it was decided not to wait for the results of the exact typing.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In a case conference with the Infectious Diseases Department, it was decided to treat the patient as visceral leishmaniasis, given the time since onset and risk of spread, with intravenous liposomal amphotericin B at a dose of 5<span class="elsevierStyleHsp" style=""></span>mg/kg on days 1, 5, and 10 (total dose 15<span class="elsevierStyleHsp" style=""></span>mg/kg),<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> according to the protocol used in the hospital. The patient responded well, with no evidence of recurrence at the six-month follow-up.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Leishmaniasis is a tropical infectious disease caused by protozoan parasites of the genus <span class="elsevierStyleItalic">Leishmania</span>, transmitted by the bite of infected sandflies. The ability of these parasites to evade the human immune system and reside in macrophages, coupled with the clinical variability of the disease, poses significant challenges for diagnosis and treatment. Genital leishmaniasis is a rare clinical condition compared to other forms of the disease. It has been reported in various tropical and subtropical regions, including Latin America, Africa, the Middle East and Asia.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Genital lesions may appear near sandfly bites or be the result of the infection spreading through the bloodstream. Conditions such as disseminated cutaneous leishmaniasis and HIV infection may be associated with genital involvement.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Our patient had no immunosuppression or other recognised risk factors associated with atypical presentations.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Symptoms of genital leishmaniasis are variable, although they generally include persistent genital ulcers, nodular lesions and inguinal lymphadenopathy. These manifestations can be confused with other sexually transmitted infections or genital cancers, which often leads to a late diagnosis,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> as in the case we have reported here.</p><p id="par0035" class="elsevierStylePara elsevierViewall">According to WHO guidelines,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the treatment of cutaneous leishmaniasis (CL) caused by <span class="elsevierStyleItalic">Leishmania infantum</span> depends on the severity of the disease and the patient’s comorbidities. For mild disease (fewer than four lesions, each less than 4<span class="elsevierStyleHsp" style=""></span>cm in size, non-immunocompromised patients), treatment includes wound care with dressings, cleansing with disinfectants, intralesional antimonials or superficial cryotherapy, and ointments containing paromomycin. Moderate disease (up to four lesions, each less than 4<span class="elsevierStyleHsp" style=""></span>cm in size, in potentially disfiguring areas) is treated with a combination of superficial cryotherapy and intralesional antimonials, or antimonials alone if cryotherapy equipment is not available, with thermotherapy as an alternative method. Severe disease (lesions larger than 4<span class="elsevierStyleHsp" style=""></span>cm in size, more than four lesions, periorificial or near small joints, significant lymphatic spread, immunosuppression or severe comorbidities) requires systemic treatment with intramuscular or intravenous pentavalent antimonials (20<span class="elsevierStyleHsp" style=""></span>mg Sb5+/kg for 10–20 days) or miltefosine (50<span class="elsevierStyleHsp" style=""></span>mg three times daily for 28 days). Early and appropriate treatment is essential to reduce morbidity and prevent serious complications.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Sources of funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">There was no funding for this article.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Informed consent</span><p id="par0050" class="elsevierStylePara elsevierViewall">Consent was obtained for publication of all patient photographs and medical information.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">AI usage statement</span><p id="par0055" class="elsevierStylePara elsevierViewall">During the preparation of this article, the authors used ChatGPT-4 (OpenAI, California, USA), with human review to improve the writing. After using this tool, the authors reviewed and edited the contents where necessary and declare themselves responsible for the content of this publication.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Data availability statement</span><p id="par0060" class="elsevierStylePara elsevierViewall">Data supporting these findings are available on reasonable request from the corresponding author. The corresponding author had full access to all the data in this manuscript and takes responsibility for its integrity.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical course and diagnosis" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Sources of funding" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Informed consent" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "AI usage statement" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Data availability statement" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 702 "Ancho" => 900 "Tamanyo" => 54127 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0160" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ulceration with raised edges on the foreskin on the dorsal aspect of the penis.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 857 "Ancho" => 1600 "Tamanyo" => 287525 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0165" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histopathological study of the lesion. Haematoxylin-eosin. Arrows indicate the presence of amastigotes of <span class="elsevierStyleItalic">Leishmania</span>.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Manual on case management and surveillance of the leishmaniases in the WHO European Region [Internet]" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Gradoni" 1 => "R. López-Vélez" 2 => "M. Mokni" ] ] ] ] ] "host" => array:2 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2017" "editorial" => "World Health Organization" "editorialLocalizacion" => "Denmark" ] ] 1 => array:1 [ "WWW" => array:1 [ "link" => "https://www.who.int/publications-detail-redirect/9789289052511" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intravenous liposomal amphotericin B efficacy and safety for cutaneous and mucosal leishmaniasis: a systematic review and meta-analysis protocol" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "F. Naeem" 1 => "K. Nathan" 2 => "J. Chivinski" 3 => "T. Ekmekjian" 4 => "M. Libman" 5 => "S. Barkati" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "BMJ Open" "fecha" => "2021" "volumen" => "11" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Challenges in diagnosis of genital ulcers: a genital leishmaniasis case series" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.D. de Souza" 1 => "A. Falqueto" 2 => "G.L. de Morais" 3 => "S. Salomão A da" 4 => "F.D. Pereira" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Rev Soc Bras Med Trop" "fecha" => "2021" "volumen" => "54" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/2529993X/unassign/S2529993X24002132/v1_202410101058/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/2529993X/unassign/S2529993X24002132/v1_202410101058/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X24002132?idApp=UINPBA00004N" ]
