Eyelid Discoid Lupus Erythematosus Misdiagnosed as Leishmaniasis
Amir Feily1, Farhang Houshmand2, Marigdalia K Ramirez-Fort3
1 Dermatologist, Department of Dermatology, Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran.
2 Dermatopathologist, Department of Pathology, Jahrom University of Medical Sciences, Jahrom, Iran.
3 Senior Resident, Department of Radiation Oncology, Medical University of South Carolina, South Carolina, USA.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Amir Feily, Dr. Feily Clinic of Dermatology, Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran; Moalem BLVD, Jahrom, Fars, Iran.
E-mail: dr.feily@yahoo.com
A 42-year-old man presented to the clinic of Dermatology and Hair Transplantation, with a two-year history of right eyelid scarring and associated eyelash alopecia. Upon initial presentation of the patient’s symptomatology, he had a positive smear test for leishmania. Therefore, he was diagnosed and treated for eyelid leishmaniasis with several rounds of cryotherapy and glucantim for two years; his lesions were refractory to this initial therapy.
General physical examination was unremarkable. Right eye examination revealed, periocular erythematous, oedematous plaques with active borders, central scarring and lower lid madarosis [Table/Fig-1]. There was no other skin lesion on the body. The lesion was clinically suspicious for cutaneous lupus and a biopsy was performed. Histopathological analysis confirmed Discoid Lupus Erythematosus (DLE) [Table/Fig-2]. Specifically, the sections showed hyperkeratosis with follicular plugging. Thinning and flattening of the stratum Malpighi with focal hydropic degeneration of the basal layer was identified. A brisk perivascular and periadnexal mononuclear lymphocytic infiltrate with some admixed melanophages, around hair follicles was seen. Vasodilation of upper dermal vessels was also present.
Right eyelid examination; periocular erythematous, oedematous plaques with active borders, central scarring and lower lid madarosis.
The skin lesion biopsy (H&E staining; Low power).
The patient was successfully treated with hydroxychloroquine 200 mg BID and prednisolone 15 mg daily, resulting in lesional resolution in six months [Table/Fig-3].
Successful treatment of the patient with hydroxychloroquine and prednisolone and lesional resolution in six months.
DLE is a chronic, autoimmune disorder that is limited to the skin; morphologically, DLE presents with characteristic acute erythema and discoid lesions [1]. Rarely does DLE involve the eyelid and periocular region [2]. Early diagnosis of DLE is important towards initiating the correct treatment and prevention of permanent scarring and discolouration [1,2]. The differential diagnosis of periocular DLE includes: psoriasis, rosacea, lupus vulgaris, sarcoidosis, Bowen’s disease, polymorphous light eruptions, lichen planopilaris, dermatomyositis, granuloma annulare, granuloma faciale and leishmaniasis [2]. There are many misdiagnosed cases in the literature based on the clinical similarities of the aforementioned conditions [3-6]. Similarly, the present patient’s treatment was delayed due to an incorrect laboratory-based diagnosis, without noticing the clinical signs. A higher index of suspicion for DLE could have accelerated the biopsy and correct management; the presented clinical scenario, emphasises the importance of physical examination and histopathological examination in dermatological diagnoses.
Patient’s consent was obtained before publishing the clinical images.
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