case_images: PMC5813668_01
case_images: - Atypical disseminated cutaneous leishmaniasis (DCL) caused by Leishmania major in a patient with opium abuse and chronic obstructive pulmonary disease before antileishmanial therapy. The patient had multiple papular, crusted, severely ulcerated and creamy, wet-looking lesions that spread to his left arm and chest
case_images: 1678-9946-rimtsp-S1678-9946201860005-gf01.jpg
case_images: PMC5813668_01_1678-9946-rimtsp-S1678-9946201860005-gf01.jpg
case_images: f01
case_images: As shown in Figure 1 , he presented with one-month history of multiple skin lesions, which started with a small furuncle on the left forelimb which progressed to other parts of the arm and hemithorax. Figure 1 ). Furthermore, the patient's lesions spread to his palm and all over the left finger nails which are very rare manifestations.
case_images: - A) Abundant intracellular amastigote forms of Leishmania
  major (arrows) in the Giemsa-stained smear; B) in the skin biopsy stained with Hematoxylin and Eosin, prepared from an ulcerated area of the left wrist and forearm of the patient with disseminated cutaneous lesions (original magnification: x1,000)
case_images: 1678-9946-rimtsp-S1678-9946201860005-gf02.jpg
case_images: PMC5813668_01_1678-9946-rimtsp-S1678-9946201860005-gf02.jpg
case_images: f02
case_images: A hypothesis of leishmaniasis was made, and further evaluation by direct examination of the skin of the wrist and forearm using lesion scraping by a vaccinostyle, under sterile conditions was performed (Giemsa staining) revealing abundant intracellular Leishmania amastigotes inside and outside host cells (3+ parasitemia grade: 1-10 parasites/microscopic field) ( Figure 2A ). H&E). Histopathological smears of wrist and forearm skin lesions revealed mild hyperkeratotic epidermis based on dermis infiltrated by numerous mixed inflammatory cells including abundant macrophages at dermis filled with amastigote forms of Leishmania ( Figure 2B ).
case_images: - Patient with atypical disseminated cutaneous leishmaniasis (DCL) showing good response to treatment with amphotericin B and regression of his cutaneous lesions
case_images: 1678-9946-rimtsp-S1678-9946201860005-gf03.jpg
case_images: PMC5813668_01_1678-9946-rimtsp-S1678-9946201860005-gf03.jpg
case_images: f03
case_images: Consequently, he was placed on amphotericin B (3 mg/kg/per day for 10 days) and showed progressive and marked improvement of cutaneous lesions ( Figure 3 ).