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\begin{document}

\title{Verrucous mass of the leg in an octogerian woman}



\author[1]{Mariem Rekik}%
\author[2]{Khadija Sellami}%
\author[1]{mariem Amouri}%
\author[3]{Saadia Makni}%
\author[3]{Naourez Gouiaa}%
\author[3]{Tahya Boudaouara}%
\author[1]{Hamida Turki}%
\affil[1]{Hedi Chaker Hospital}%
\affil[2]{Hopital Hedi Chaker}%
\affil[3]{Hopital Habib Bourguiba}%


\vspace{-1em}



  
  \date{May 23, 2024}


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\selectlanguage{english}
\begin{abstract}
Various clinical forms of cutaneous leishmaniasis can be encountered
such as: ulcerated, lupo\selectlanguage{ngerman}ïd, sporotrichoïd and other rare forms
(eczematiform, erysipeloid, psoriasiform, verrucous, and pseudotumoral).
We report an atypical presentation. Dermatologists should be aware when
facing a verrucous mass, especially if the patient comes from an endemic
country.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


Introduction:

Cutaneous leishmaniasis (CL) is endemo-epidemic in the center and south
of Tunisia. We report a verrucous form mimicking squamous cell
carcinoma.

Case presentation:

A 80- year old woman with no medical record is presented to our
department for a 3-month history of budding tumor on her left leg. It
had started as a papule which progressively enlarged and became
verrucous. Physical examination shows a painless verrucous mass
measuring 5 cm in diameter, on the external face of the left leg's lower
extremity (Figure 1). There were no palpable regional nodes. The leg
lesion was biopsied (Figure 2, 3). Histopathology revealed epidermal
hyperkeratosis with a dense inflammatory infiltration of lymphocytes,
plasmocytes and histiocytes (Figure 2) containing intracellular
basophilic small and rounded structures which turned blue after Giemsa's
staining; these organisms were consistent with
\emph{leishmania}amastigotes (Fig.3). The diagnosis of verrucous and
pseudotumoral cutaneous leishmaniasis (CL) was established. The patient
was treated by cryotherapy once a week for 4 months with good results:
the lesion has~almost been completely resolved at 5 months, leaving a
dyschromic scar.

Discussion:

Leishmaniasis is a protozoan infection that occurs worldwide. It has
diverse clinical presentations and may represent a public health problem
in endemic countries {[}1{]}. Various clinical forms can be encountered
such as: the ulcerated and crusted form, the lupo\selectlanguage{ngerman}ïd form, the
sporotrichoïd form and other rare forms (eczematiform,
erysipeloid,~psoriasiform, verrucous, and pseudotumoral) {[}2{]}. These
uncommon presentations represent 2-5\% of CL clinical presentations
{[}3{]}. Small number of cases of verrucous and tumor-like forms had
been reported in previous series {[}2{]}. The most important
differential diagnosis is the verrucous variant of squamous cell
carcinoma {[}4{]}. The diagnosis of CL may be made using several
methods. The most common ones are tissue smear and skin biopsy with
Giemsa staining in order to identify~\emph{Leishmania} amastigotes. The
culture enables to identify the specimen but PCR has a higher
sensitivity.~ The treatment of CL can be topical or systemic.
Cryotherapy alone can be efficient, particularly in the case of a small
number of lesions {[}5{]}. Most of the published cases of verrucous CL
were treated systemically {[}2,3,4{]}.

The peculiarity of our case consists in its striking resemblance to
verrucous squamous cell carcinoma which refers to the verrucous and
pseudotumoral presentation, and the response to cryotherapy without need
for systemic treatment.

\textbf{Conclusion:}

We report an atypical presentation of CL. Dermatologists should be aware
of this form of CL when facing a verrucous mass, especially if the
patient comes from a CL endemic country.

Author contribution:

Rekik Mariem: Have made substantial contributions to conception and
design, or acquisition of data, or analysis and interpretation of data;
and have been involved in drafting the manuscript or revising it
critically for important intellectual content; and Agreed to be
accountable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.

Sellami Khadija: Have made substantial contributions to conception and
design, or acquisition of data, or analysis and interpretation of data;
and have been involved in drafting the manuscript or revising it
critically for important intellectual content; and Agreed to be
accountable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.

Amouri Meriem: Have been involved in drafting the manuscript or revising
it critically for important intellectual content; and Agreed to be
accountable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.

Makni Saadia: Agreed to be accountable for all aspects of the work in
ensuring that questions related to the accuracy or integrity of any part
of the work are appropriately investigated and resolved.

Gouiaa Naourez: Agreed to be accountable for all aspects of the work in
ensuring that questions related to the accuracy or integrity of any part
of the work are appropriately investigated and resolved.

Boudaouara Tahya: Agreed to be accountable for all aspects of the work
in ensuring that questions related to the accuracy or integrity of any
part of the work are appropriately investigated and resolved.

Turki Hamida: Have made substantial contributions to conception and
design, or acquisition of data, or analysis and interpretation of data;
have been involved in drafting the manuscript or revising it critically
for important intellectual content; have given final approval of the
version to be published and agreed to be accountable for all aspects of
the work in ensuring that questions related to the accuracy or integrity
of any part of the work are appropriately investigated and resolved.

\textbf{References:}

\begin{enumerate}
\tightlist
\item
  Conrad NL, Hanson SG, Hsu S.What~caused~this~verrucous~plaque?Postgrad
  Med. 2001 Mar;109(3):139-41.
\item
  Meireles CB1,~Maia LC1,~Soares GC1 et.al. Atypical presentations of
  cutaneous~leishmaniasis: A systematic review.Acta Trop.~2017
  Aug;172:240-254
\item
  Rodríguez-Zúñiga MJM1,2,~Idrogo-Bustamante J1,2,~Quijano-Gomero E1.
  Verrucous~cutaneous~leishmaniasis: unusual presentation. Rev Peru Med
  ExpSaludPublica.~2017 Apr-Jun;34(2):344-345
\item
  Salman A, Yucelten AD, Seckin D, et
  al.Cutaneous~leishmaniasis~mimicking~verrucous~carcinoma: A case with
  an unusual clinical course.Indian J DermatolVenereolLeprol. 2015
  Jul-Aug;81(4):392-4
\item
  Masmoudi~A1,~Hariz W,~Marrekchi S. et al. Old World
  cutaneousleishmaniasis:~diagnosis~and~treatment.JDermatol Case
  Rep.~2013 Jun 30;7(2):31-41.
\end{enumerate}\selectlanguage{english}
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