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Erythematous Nodule With Central Crust on the Nail Fold in an Infant

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A girl younger than 2 years presented with a 7-month history of an inflammatory plaque on her left index finger (Figure, A). This lesion had started as a light erythema a few months before, initially oriented as a bacterial paronychia or herpetic whitlow and treated with an oral antibiotic (amoxicillin) and antiviral (acyclovir) without improvement. There was no relevant medical history. The family reported living in a rural area on the Mediterranean coast.

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C. Cutaneous leishmaniasis

Histopathologic findings revealed a diffuse dermal inflammatory infiltrate consisting of lymphocytes, plasma cells, small epithelioid granulomas (Figure, C), and histiocytes containing leishmania amastigotes (Figure, D). Given the clinical and histopathologic findings, a diagnosis of cutaneous leishmaniasis was made, and because the patient had only 1 lesion, treatment with intralesional meglumine antimoniate was initiated. Improvement and resolution of the lesion were observed after 2 infiltrations with no adverse effects.

Leishmaniasis is caused by an intracellular parasite transmitted to humans by the bite of a sand fly.1 In Spain, cutaneous leishmaniasis caused by Leishmania infantum is common, especially in endemic areas mainly located on the Mediterranean coast.2 Because of the enhanced opportunity for exposure and possibly not having a fully developed immune system, children may be more susceptible to infection than adults3 and constitute 7% to 10% of cases in endemic regions.4

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Article Information

Corresponding Author: Aina Vila-Payeras, MD, Department of Dermatology, Son Llàtzer Hospital, Carretera Manacor km 4, Palma de Mallorca 07198, Spain (ainavila91@hotmail.com).

Published Online: August 5, 2020. doi:10.1001/jamadermatol.2020.2406

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient’s mother for granting permission to publish this information.

References
1.
Torres-Guerrero  E , Quintanilla-Cedillo  MR , Ruiz-Esmenjaud  J , Arenas  R .  Leishmaniasis.   F1000Res. 2017;6(May):750.PubMedGoogle ScholarCrossref
2.
Vera-Izaguirre  DS , Vega-Memije  E , Quintanilla-Cedillo  MR , Arenas  R .  Leishmaniasis.   Dermatologia Cosmet Medica y Quir. 2006;4(4):252-260.Google Scholar
3.
Handler  MZ , Patel  PA , Kapila  R , Al-Qubati  Y , Schwartz  RA .  Cutaneous and mucocutaneous leishmaniasis.   J Am Acad Dermatol. 2015;73(6):897-908.PubMedGoogle ScholarCrossref
4.
Layegh  P , Moghiman  T , Ahmadian Hoseini  SA .  Children and cutaneous leishmaniasis.   J Infect Dev Ctries. 2013;7(8):614-617. https://www.ncbi.nlm.nih.gov/pubmed/23949297.PubMedGoogle ScholarCrossref
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Heras-Mosteiro  J , Monge-Maillo  B , Pinart  M ,  et al.  Interventions for Old World cutaneous leishmaniasis (review).   Cochrane Database Syst Rev. 2017;2017(12):394.Google Scholar
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Desjeux  P .  Leishmaniasis.   Comp Immunol Microbiol Infect Dis. 2004;27(5):305-318. https://www.ncbi.nlm.nih.gov/pubmed/15225981.PubMedGoogle ScholarCrossref
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Bari  AU , Rahman  SB .  Many faces of cutaneous leishmaniasis.   Indian J Dermatol Venereol Leprol. 2008;74(1):23-27.PubMedGoogle ScholarCrossref
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Iftikhar  N , Bari  I , Ejaz  A .  Rare variants of cutaneous leishmaniasis.   Int J Dermatol. 2003;42(10):807-809.PubMedGoogle ScholarCrossref
9.
Uribe-Restrepo  A , Cossio  A , Desai  MM , Dávalos  D , Castro  MDM .  Interventions to treat cutaneous leishmaniasis in children.   PLoS Negl Trop Dis. 2018;12(12):e0006986.PubMedGoogle Scholar
10.
Rubiano  LC , Miranda  MC , Muvdi Arenas  S ,  et al.  Noninferiority of miltefosine versus meglumine antimoniate for cutaneous leishmaniasis in children.   J Infect Dis. 2012;205(4):684-692.PubMedGoogle ScholarCrossref
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