2015, Volume 31, Number 2, Page(s) 126-130
Clinicopathological Evaluation of Cutaneous Leishmaniasis in the Mediterranean Region of Turkey
Cumhur İbrahim BAŞSORGUN1, Betül ÜNAL1, Ayşe AKMAN KARAKAŞ2, Erkan ALPSOY2, Mehmet Akif ÇİFTCİOĞLU1, Soner UZUN2
1Department of Pathology, Akdeniz University, School of Medicine, ANTALYA, TURKEY
2Department of Dermatology, Akdeniz University, School of Medicine, ANTALYA, TURKEY
Keywords: Cutaneous leishmaniasis, Pathology, Granuloma
Cutaneus leishmaniasis, a chronic self-limited disease
of the skin, is usually caused by Leishmania Tropica. It is endemic
in Southeastern Anatolia. The definitive diagnosis depends
on demonstration of the parasites by smear and culture or its
identification in tissue section. This study aimed to evaluate clinical
and histopathological skin lesions in cutaneous leishmaniasis cases in
Material and Method: Our study included 28 patients diagnosed
with cutaneous leishmaniasis at the Pathology Department of
Akdeniz University Medical Faculty. Histopathological sections were
stained with Haematoxylin-Eosin, Giemsa or Leishman for visual
examination of cellular components by two dermatopathologists. The
epidermal (acanthosis, hyper-parakeratosis, atrophy, lymphocytic
exocytosis) and dermal changes that may indicate lymphohistiocytic
infiltration and granuloma formation were investigated. The parasitic
load was classified according to the modified Ridley's parasitic index.
Results: Out of 28 cases, 11 had hyperparakeratosis, 17 had
orthokeratosis, 20 had acanthosis, 4 had epidermal atrophy, and 7 had
exocytosis. Typical epithelioid cell granulomas with giant cells and
a rim of lymphocytes were present in 16 cases. Leishman-Donovan
bodies were extremely rare in typical granulomatous lesions. The
other 12 cases showed lymphohistiositic infiltration, giant cells and
prominent plasma cells. There were numerous Leishman-Donovan
bodies in these lesions.
Conclusion: We investigated the epidermal and dermal changes
that would facilitate the histopathological diagnosis of cutaneous
leishmaniasis in this study. We found that atrophy, acanthosis,
and orthokeratosis were early stage indicators, while exocytosis,
hyperparakeratosis, and atrophy were indicative of late stage disease.
Cutaneous leishmaniasis (CL) is a serious health problem
with an increasing worldwide incidence, particularly
in tropical regions. The disease is an endemic in the
Southeastern Anatolia and Mediterranean regions of
Turkey, and mainly concentrated in the Çukurova area1
In recent years, an increased incidence of CL cases has been
observed in Antalya and its environs2
CL is a granulomatous skin disease. This group of diseases
usually present with various clinical manifestations, which
can pose occasional diagnostic challenges both clinically
The main agent causing CL is an intracellular parasite called
L. tropica. The differential diagnosis of CL requires an
accurate identification of the causative parasite. The fastest
and easiest method of diagnosis is identifying the causative
agent by microscopic examination of Giemsa-stained
smears prepared from skin lesions. Identification of the
etiological agent from histopathological sections appears
to be an important diagnostic tool. Other sensitive modern
diagnostic techniques include immunohistochemical
and immunofluorescence techniques using monoclonal
antibodies, identifying the causative agent through DNA
probes, PCR, and electron microscopic studies.
The disease is usually misdiagnosed in non-endemic
countries, which leads to significant delays in the treatment
of the skin lesions. In general, the disease has complex
clinical manifestations such as plaques, papules, nodules or
nodulo-ulcerative and lupoid lesions. However, the lesions
may become more complicated due to overlapping lesions
or secondary infections in patients with delayed diagnosis.
These complications might lead to further clinical or
histopathological difficulties. Combined with conventional
histopathological features, confusing additional findings
might interfere with the diagnostic accuracy.
In this study, we examined the histopathological features
of the patients diagnosed with CL and evaluated the
relationship with the clinical process.
Our study included 28 patients diagnosed with CL at the
Pathology Department of Akdeniz University Medical
Faculty. We identified the intra-and extra-cellular parasites
by histopathological examinations in all cases.
The 4-micron-thick histopathological sections were stained
with histochemical dyes such as Haematoxylin and Eosin
(H&E), Giemsa or Leishman for visual examination of cellular components by two dermatopathologists.
Epidermal changes, acanthosis, hyper-parakeratosis,
epidermal atrophy, exocytosis (lymphocytic) and dermal
changes were considered to indicate the presence of
lymphohistiocytic infiltration and granuloma formation.
The parasitic load was examined at high magnification (40x
objective) and classified according to the modified Ridley's
parasitic index4 as +1 for 1-10 parasites, +2 for 10-100
parasites, and +3 for 100 or above parasites per standard
section. A parasitic index of +1 and +2 were defined as
“low”, and a parasitic index of +3 as “high”.
Statistical Analysis: The Kolmogorov-Smirnov test was used
to verify the normality of the distribution of continuous
variables. Since the duration of disease was not normally
distributed, comparison between two groups was made
using the Mann-Whitney U test while the chi-square test
was used for categorical variables. Analyses were performed
with PASW 18 (SPSS/IBM, Chicago, IL, USA) software and
two-tailed P value less than 0.05 was considered statistically
The mean age of the patients was 19±8.74 years. 19 patients
were male and 9 were female. The mean clinical duration of
disease was 10.5±6.53 months. The lesions were localized
on the face in 18 patients (64.2%), upper extremities in 5,
lower extremities in 3 and on the back in 2 patients.
We detected papules or nodules in 10 cases, noduloulcerative
lesions in 13 cases and lupoid lesions in 5
cases. Of the 28 patients, 11 had hyper-parakeratosis, 17
orthokeratosis, 20 acanthosis, 4 atrophy and 7 exocytosis.
Granuloma formation was observed in all of the patients
showing exocytosis and hyper-parakeratosis. Orthokeratosis
was observed in all cases demonstrating lymphohistiocytic
infiltration with no granulomatous features. The Grenz
zone was apparent in the cases with lymphohistiocytic cell
All 12 patients with lymphohistiocytic cell infiltration
showed a parasitic index level of +3 (Figure 1), while 14
patients with granuloma showed a parasitic index level of
+1 in 12 cases and +2 in 2 cases (Figure 2).
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|Figure 1: Early lesion of acute cutaneous leishmaniasis showing
a mixed inflammatory cell infiltrate. The infiltrate includes
parasitized macrophages, plasma cells and lymphocytes. (H&E;
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|Figure 2: Late lesion of acute cutaneous leishmaniasis showing
an infiltrate predominantly composed of parasitized macrophages
with a variable number of lymphocytes, hyperparakeratosis and
acanthosis (H&E; x100).
Of the patients with lymphohistiocytic cell infiltration, 10
had papules or nodules, while 2 patients presented with
nodulo-ulcerative lesions. Granuloma formation was
observed in all lupoid lesions. Patients demonstrating
granuloma formation were chronic cases. In these cases, the
median duration of the disease was 12.5 (min.10-max.26)
months, and the parasite index level was low. Patients demonstrating lymphohistiocytic cell infiltration were
acute cases with a median disease duration of 4 (min.2-
max.13) months and high index levels (Table I).
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|Table I: Distribution of patients by age, sex, lesion type, lesion site, histopathological features, parasitic index and duration
The patients with granuloma formation and those with
lymphohistiocytic infiltrate were statistically compared.
The number of parasites in 12 cases with lymphohistiocytic
infiltrate was quite high. The parasite count was lower
in the 14 patients with granuloma formation. Due to a
relatively small sample size, patients with parasitic index
+1 and +2 were defined as “low”, and parasitic index +3
was defined as “high”. The comparison of the parasite index
in cases with lymphohistiocytic infiltrate and granuloma
formation showed a p value of 0.001 after the Chi-square
test, which was statistically significant. We found that the
number of parasites was significantly high in acute cases
with lymphohistiocytic infiltrate, whereas chronic cases
presenting granuloma formation had a relatively lower
parasite count. These findings were statistically significant
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|Table II: The distribution of patients according to parasitic index, granuloma formation and lymphohistiocytic infiltrate
Cases with lymphohistiocytic infiltration had a significantly
lower median disease duration than those with granuloma
formation. The Mann-Whitney U test showed a p value
of 0.001 in the comparison of duration of disease with
lymphohistiocytic infiltrate and those with granuloma
formation. Another comparison that evaluated those with
a median disease duration of less than 12 months and
over 12 months revealed statistically significant results.
15 cases with a disease duration of less than 12 months
were acute and 13 cases with over 12 months were chronic.
The comparison of median disease duration in cases with lymphohistiocytic infiltrate and granuloma formation
showed a p value of 0.001 after the Chi-square test, which
was statistically significant.
Over the recent years, cutaneus leishmaniasis (CL) has
attracted more attention due to its increasing incidence
in subendemic regions. Cases of CL are also seen in nonendemic
areas, mainly in people with a history of recent
travel to endemic regions. The disease usually presents
with painless skin lesions in the external parts of the
body. In addition, superinfections or incorrect treatment
procedures may complicate the clinical picture and create
difficulty in diagnosis, which may delay the treatment.
Atypical presentations of the disease can also compromise
the accuracy of the diagnosis and treatment.
Lever has classified the early and late stage lesions based
on their duration as “acute leishmaniasis”, characterized by
the presence of lesions lasting 1-2 years from emergence,
and “chronic leishmaniasis”, characterized by the presence
of lesions lasting more than 2 years5. In the early stages,
clinical findings include papules, nodules, plaques and
nodulo-ulcerative lesions, while in the late stages, lupoid
lesions are observed. For patients in subendemic areas such
as Antalya, substantial overlap lesions occur especially in
the late stages if the disease is not included in the diagnostic
considerations, which makes the pre-diagnosis challenging.
In this case, the histopathological findings might be
misinterpreted by the pathologist as other granulomatous
lesions, inflammation, ulceration, or even lymphoma. To reduce such problems, CL should always be included in the
differential diagnosis during the clinical and pathological
evaluation of the cases.
Recognition of the parasite in the examination of a touch
preparation from cutaneous lesions is one of the most
challenging aspects in the diagnosis. Histochemical staining of the cells with Giemsa or Giemsa modified
Leishman's stain exposes the intracellular and extracellular
parasites. In histopathological sections, the parasites
may be confused with tingible body, fungal elements,
toxoplasma, histoplasmosis or artifacts. At times, especially
in the granulomatous lesions of chronic leishmaniasis,
identifying the parasite can be difficult. In this case, a
microscopic examination using numerous serial crosssections
will be a correct choice. In our study, we detected
several Leishmania particles in granuloma structures
after analyzing numerous series of cross-sections. In
cases where H&E or Giemsa staining fails to identify any
Leishmania particles, other sensitive diagnostic techniques,
including immunohistochemical and immunofluorescence
techniques as well as molecular methods such as DNA
probes or PCR, can be used to identify the causative agent.
In the early stages of CL, a histopathological examination
might reveal plasma cells or giant cells along with
lymphohistiocytic cell infiltration. At this stage, the parasite
load is quite heavy in patients. In the later stages of the
disease, the number of parasites gradually decreases in
proportion to the disease duration, and distinct granuloma
structures are observed. Consistent with the results of the
previous research, our study detected similar characteristic
In the histopathological diagnosis of CL, epidermal changes
may have a significant diagnostic value. While Mahregan
et al. reports that patients in the early stages of the disease
may demonstrate hyper-parakeratosis, atrophy, acanthosis,
exocytosis, pseudoepitheliomatous hyperplasia, and basal
vacuolar degeneration5, we only observed atrophy,
acanthosis and orthokeratosis in our cases at early stages. In
the late stages, we detected exocytosis, hyper-parakeratosis
and atrophic lesions. Although these findings are not
statistically significant due to the limited sample size, we
consider that further studies with larger sample sizes can
provide new data other than the current histopathological
features, which will contribute to the diagnosis of CL.
Definitive diagnosis of CL can only be made by
histopathological identification of the parasite. In cases
with lymphohistiocytic infiltration and granulomatous
inflammation where the causative parasite cannot be
identified, CL should be included in the diagnostic
considerations. As in all types of skin diseases,
clinicopathological correlation is also required in the
diagnosis of CL.
1) Uzun S, Uslular C, Yucel A, Acar MA, Ozpoyraz M, Memisoglu
HR. Cutaneous leishmaniasis: Evaluation of 3074 cases in the
Cukurova Region of Turkey. Br J Dermatol. 1999;140:347-50.
2) Akman A, Durusoy C, Seckin D, Alpsoy E. Antalya' da görülen
Kutanoz Layşmanyazis olgularının epidemiyolojik özellikleri.
3) Memisoglu HR. Kutanöz leishmaniasis. Aknem Derg.
4) Ridley DS, Ridley MJ. The evaluation of the lesion in cutaneous
leishmaniasis. J Pathol. 1983;141:83-96.
5) Lever WF. Histopathology of the skin. 9th ed. Philadelphia: JB
Lippincott Company; 2004.
6) Venkataram M, Moosa M, Devi L. Histopathological spectrum
in cutaneous leishmaniasis: A study in Oman. Indian J Dermatol
Venereol Leprol. 2001;67:294-8.
7) Ridley DS. A histological classification of cutaneous leishmaniasis
and its geographical expression. Trans R Soc Trop Med Hyg.