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Lupoid leishmaniasis of the nose responding well to cryotherapy

A 23-year-old girl from Tunisia presented to our dermatology department in May 2007 with a 9-month history of a slowly enlarging, asymptomatic nodule of the nose. Her medical history was unremarkable. Clinical examination showed a 2-cm diameter, well-demarcated, granulomatous nodular lesion of the tip of the nose (FIG. 1A). The lesion was painless and had an erythematous, large, raised border with numerous papules and a mild scaling (FIG. 1B).There was no cervical lymphadenopathy, and no evidence of organomegaly. The hematologic and biochemical studies were all within normal limits. A direct smear from the exudate of fluid obtained by needle aspiration of the lupoid lesion was stained with Giemsa for leishmania parasite. A biopsy was performed, and a part of the tissue was used for culture. The smear showed leishmania bodies, and the culture was negative. The histopathological examination showed hyperkeratosis, parakeratosis, and acanthosis within the epidermis. The dermis was filled with aggregates of large, pink histiocytes and mixed chronic inflammatory cells. The histiocytes contained dot-like organisms typical of CL (FIG. 1C). The patient was admitted for a daily intramuscular injection of meglumine antimoniate (60 mg/kg), but no improvement was obtained 2 weeks later. Then, she received ketoconazole 200 mg daily for 1 month. The patient was controlled 4 months later, and the lesion still showed no evidence of healing. She was admitted again for a second 15-day course of intramuscular injection of meglumine antimoniate (60 mg/kg). After 2 months, only a mild improvement was noted. The present authors attempted to identify the parasite agent of this resistant case of CL by polymerase chain reaction (PCR) method. Unfortunately, the result of PCR yielded negative. The cutaneous lesion was disfiguring and had a psychosocial impact on our patient. So, the present authors decided to try cryotherapy. A handheld unit for spraying (Cry-ac, Brymill, CA) with a 1-mm nozzle was used to spray liquid nitrogen on the lesion. The spraying was performed at a 2-cm distance between the nozzle and the lesion for 10–15 seconds until the freezing reached up to a few millimeters within the healthy skin surrounding the lesion. Applications were repeated until the entire lesion was included. Cryotherapy was performed every 2 weeks.The lesion healed completely after six sessions with very good cosmetic result (FIG. 2). The patient was followed-up for 1 year and showed no signs of recurrence. LL, also known as chronic or relapsing leishmaniasis, is usually resistant to conventional therapies. Diagnosis of LL may be difficult if no parasites are detected. In fact, leishmaniasis amastigotes are frequently absent on microscopy, and culture for leishmaniasis is frequently negative. PCR method had a sensitivity of about 45.5% in LL. There is no standardized treatment for this condition. Treatment options include local injection of amphotericin B (1); combination of systemic meglumine antimoniate and allopurinol (2); triple therapy with paramomycin, cryotherapy, and intralesional meglumine antimoniate (3); combination therapy of topical trichloroacetic acid (TCA) and systemic meglumine antimoniate (4); and carbon dioxide laser (5). These wide ranges of therapies may be expensive, toxic, and not so effective in the treatment of LL. Our patient, who responded