Cutaneous Leishmaniasis in an American Sol‐dier Who Returned from Iraq – A Case Report

Abstract

A 27‐year‐old male soldier who was stationed in Iraq from 3/03 to 9/03 presented to a local dermatologist in 4/04 with several red slightly raised non‐ulcerated nodules over the right wrist and ventral arm developed 2–3 months prior to the visit. The clinical impression was sporotrichosis. A punch biopsy was performed on a subcutaneous nodule and showed a granulomatous inflammatory process with scattered loosely organized clusters of epithelioid histiocytes palisading around dermal mucin, mainly involving the papillary and mid dermis. A diagnosis of granuloma annulare was suggested. Intralesional triamcinolone was used and the lesions initially improved but later recurred. However on deeper sections, there were scattered granulomas with a dominant necrotizing granuloma consisting of epithelioid histiocytes palisading around a central area of necrosis surrounded by lymphoplasmacytic and neutrophilic infiltrates. In 5/04, he presented to the Birmingham VA Medical Center with similar lesions. A repeat biopsy again showed a necrotizing granulomatous inflammation. In addition, numerous intracytoplasmic organisms with kinetoplasts were present within histiocytes. The findings were consistent with leishmaniasis due to L. major as confirmed by polymerase chain reaction at Walter Reed Hospital. As more US soldiers return from the Middle East, previously rare cutaneous leishmaniasis will be seen more commonly.