Rev. Soc. Bras. Med. Trop. vol.28 número1

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R e v is ta d a S o c ie d a d e B r a s ile ir a d e M e d ic in a T ro p ic a l 2 H (l):4 5 - 4 7 , ja n - m a r , 19 95 .

RELATO

CASO,,

SPONTANEOUS REGIONAL HEADING OF EXTENSIVE SKIN

LESIONS IN DIFFUSE CUTANEOUS LEISHMANIASIS (DCL)

**Jackson M.L* Costa, Ana**

Cristina

R. Saldanha, Conceição de Maria P. e

Silva, Maria dos Remédiqs

F.C. Branco,

Aldina Barrai, Edgard M. Carvalho

e

Achiléia L. Bittencourt

T h e a u th o r s r e p o r t a c a s e o f d iffu se c u ta n e o u s leish m a n ia sis, w ith lo n g sta n d in g evo lu tio n a n d p r e s e n tin g w ith d iffu se in filtra te d le sio n s ric h in a m a stig o tes in th e a b se n c e o f m u c o sa l inv o lvem e n t. In situ c h a ra c te riza tio n with m o n o c lo n a l a n tib o d ies r e v e a le d Leishmania

amazonensis.

L a r g e re g io n a l le sio n s h a v e p r e s e n te d s p o n ta n e o u s h ea lin g w ith o u t sp e c ific th e ra p y. C o n sid e rin g th a t D C L p r e s e n ts with a d e fe c t in th e cellu la r im m u n e re sp o n se , th is fa c t d e m o n str a te th a t th is p a tie n t m ay d e v e lo p a re g io n a l ce llu la r im m u n e resp o n se en o u g h to d e s tr o y th e p a ra s ite s a n d to p r o d u c e clea rin g o f so m e lesions.

K e y -w o rd s: D iffu se c u ta n e o u s le ish m a n ia sis. S p o n ta n eo u s r e g io n a l h e a lin g lesions.

Leishmania amazonensis infection.

Diffuse cutaneous leishmaniasis (DCL) is a

polar form of cutaneous leishmaniasis that in the

New World is caused by

L e is h m a n ia m e x ic a n a

and

L e i s h m a n i a a m a z o n e n s i s ,

The disease is

characterized by presence of disseminated nodules

on the body or infiltrated plaques with only

superficial and slight involvement; negative

in v iv o

and

in v itr o

tests for evaluation of cellular mediated

immunity (CMI); a long life presence of a great

quantity of parasites in lesions; high levels of

specific antibodies; unresponsiveness to the usual

anti-leishmanial therapy5 6.

Spontaneous healing of small lesions has been

referred in DCL13 4. Here we report a case of DCL

presenting with extensive regional scars and atrophic

skin representing spontaneous healing of some

lesions.

CASE REPORT

RNMG, 7 year old male, from the state of

Departamento de Patologia, Faculdade de Medicina da Universidade Federal do Maranhão, São Luís, MA e Universidade Federal da Bahia, Salvador, BA.

Address lo: Prof, Jackson M.L. Cosla. Deplo. de Patologia/ UFMA. Pça. Madre Deus 2, 65025-560 São Luís, MA, Brasil. Fax:(098)222-5135,

Recebido para publicação em 12/07/94.

Maranhão, admitted at the hospital in 1983 with

three year history of infiltrated lesions throughout

the body, that began as an infiltrated plaque in the

anterior aspect of the left leg (Figure 1A), diffuse

infiltration of the ears (Figure 2A) and nose, several

nodules in the upper limbs. No other abnormalities

were observed on physical examination. Intradermal

skin testing with leishmania antigen was negative.

A biopsy of the infiltrated plaque on the leg revealed

epidermal atrophy. Unna’s band and a heavy

infiltration of vacuolated macrophages full of

amastigotes. The patient was discharged before

using the specif treatment by request of the family.

He remained without medical care until 1991, when

he was re-admitted. As this time he presented with

a complete healing of the ear lesions (Figure 2B). In

the anterior aspect of the left leg, in the same area

of the previous lesion an extensive hypocromic scar

was observed (Figura IB). The lesions of the upper

limbs remained and new others appeared on the

face, right elbow, and left toe, associated with a

diffuse infiltration of the upper lip. An

in s i tu

characterization using monoclonal antibodies against

L . a m a z o n e n s is

yielded positive results. Thespecific

blastogenesis and skin tests for leishmaniasis were

negative. Serology by indirect fluorescent antibody

test was positive (titer 1:2.048).

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R e la to d e C a so . C o s t a J M L , S a ld a n h a A C R , S il v a C M P , B r a n c o M R F C , B a r r a i A , C a r v a l h o E M , B i t t e n c o u r t A L . S p o n ta n e o u s r e g io n a l h e a lin g o f e x te n s iv e s k in le sio n s in d iffu s e c u ta n e o u s le ish m a n ia s is (D C L ). R e v is ta d a S o c ie d a d e B r a s ile ir a d e M e d ic in a T r o p ic a l 2 8 :4 5 -4 7 , ja n - m a r , 1995 .

F ig u re I B - T h e sa m e p a tie n t a ffter eig h t y e a r s , sh o w  in g a n e x ten siv e h y p o c h ro m ic s c a r in th e a n te rio r a sp e c t o f th e leg w ith sp o n ta n eo u s h ea lin g .

DISCUSSION

DCL is considered as an anergic form of

leishmaniasis, be cause the tests that evaluate the

CMI are always negative and the parasites proliferate

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R e la to d e C a so . C o s t a J M L , S a l d a n h a A C R , S il v a C M P , B r a n c o M R F C , B a r r a i A , C a r v a l h o E M , B i t t e n c o u r t A L . S p o n ta n e o u s r e g io n a l h e a lin g o f e x te n s iv e sk in le sio n s in d iffu s e c u ta n e o u s le ish m a n ia s is (D C L ). R e v is ta d a S o c ie d a d e B r a s ile ir a d e M e d ic in a T r o p ic a l 2 8 :4 5 -4 7 , ja n - m a r , 19 95 .

not necessarily the same in all lesions of the same

patient. This is also evidenced by the spontaneously

healing of some regional lesions while others persist.

Spontaneous involution of small lesions has

been referred in DCL114; but in the present case

lesions were extensive and disappeaered leaving

scars and atrophic skin. Bittencourt et al2 have

shown through histological and ultrastructural

studies evidence that there is a focal and limited

CMI response in DCL, insufficient to control the

infection but able to promote the spontaneous

regression of same regional lesions. The observation

of the present case indicate that cell mediated

mechanisms may operate even in extensive areas of

the skin in DCL.

RESUMO

O s a u to res relata m um c a so d e leish m a n io se cu tâ n ea difu sa, co m longa evolução e p r e s e n ç a d e lesõ es infiltradas d ifu sa s ric a s em a m a stig o ta s h a v e n d o a u sê n c ia d e en vo lvim e n to m u co so . A c a ra c te riza ç ã o

in situ

co m an tic o rp os m o n o c b n a is revelo u Leíshmaniaamazonensis. D u ra n te a evo lu çã o d e su a d o e n ç a , e x te n s a s lesõ e s r e g io n a is a p r e s e n ta r a m c ic a tr iz a ç â o e s p o n tâ n e a , C o n sid e ra n d o q u e a L C D a p re se n ta -s e c o m um d é fic it n a resp o sta im un e c e lu la r, e ste f a t o d e m o n str a q u e o p a c ie n te p o d e te r d e s e n v o lv id o u m a r e sp o sta im u n e

c e lu la r re g io n a l ca p a z d e d e s tru ir o s p a r a s ita s e p r o d uzir cica triza çâ o d e a lg u m a s lesõe s.

P a la v r a s -c h a v e s : L e is h m a n io s e c u tâ n e o -d ifu s a . C ica triz e sp o n tâ n e a . L e s õ e s reg io n a is. Leishmania