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Cutaneous leucocytoclastic vasculitis in visceral leishmaniasis

In June 2014, a 50-year-old Bangladeshi woman presented for evaluation of her six-month history of irregular fever, significant weight loss and recurrent, painful purpuric lesions. The cutaneous eruptions were bilateral, painful, associated with leg oedema and used to disappear spontaneously. She had neither significant symptoms nor any past or family history, and she had not taken any recent medication. Physical examination revealed purpura, confined to her lower limbs (Figure 1), moderate anaemia and hepato-splenomegaly (4 cm and 8 cm from the right and left costal margins, respectively). Laboratory investigations revealed anaemia (Hb 79g/L), normal white cell count (2K/mcL) with normal differentials and normal platelet count (150K/mcL). The total protein was raised (108 g/L) but albumin was low (26 g/ L). The erythrocyte sedimentation rate and C-reactive protein were elevated (135mm/h and 440mg/L, respectively). Immuno-chromatography for VL was positive and the splenic aspirate also showed the presence of Leishman-Donovan (LD) bodies. The histopathological analysis of a skin biopsy taken from a purpuric lesion revealed leucocytoclastic vasculitis, but there was no deposition of immunoglobulin or complement in the immunofluorescence test. Serology for rheumatoid factor (RF) and anti-citrullinated peptide antibodies were positive, but antinuclear antibodies and anti-neutrophil cytoplasmic antibodies were negative. Complement levels were normal and serological markers for hepatitis B and C were also negative. Polyclonal gammopathy was detected in protein electrophoresis. A diagnosis of cutaneous leukocytoclastic vasculitis, associated with VL, was made. Treatment with a single dose of liposomal amphotericin-B was given. The fever subsided and the rash disappeared after five days, leaving hyper-pigmented areas over the legs (Figure 2). On follow-up four months later, there was no LD-body in a repeat splenic aspirate. After eight months of treatment, both the spleen and the liver had reduced to 3 cm and 2 cm from the left and right costal margins, respectively, and there was no reappearance of purpura.