Cutaneous Leishmaniasis Masquerading as Diabetic Foot: A Call for Vigilance.

parts of the world (1,2). CL is characterized by significant clinical variability. An ulcerated nodule on the exposed parts of the body (corresponding to the parasite inoculation site by the vector insect) is the classic presentation. However, other forms of clinical presentations also exist (3,4). CL can be present on unusual locations such as the scalp, the genital region, or palmoplantar areas. Localization in the foot poses a diagnostic challenge due to similarity to disorders which produce ulcerations. The latter include diabetes and leprosy. A 75-year-old Afghani man presented with a large, progressive, cutaneous necrotic ulcer on the left foot (Figure 1) associated with pain, one year in duration. The patient has no history of trauma or any chronic systemic disorders. Additionally, the patient reported no similar diseases in the past. The patient was repeatedly diagnosed with diabetic foot in his village. Dressings were administered several times without any improvement. The patient underwent blood tests, including fasting blood sugar, which were all within normal limits. As the patient lived in an endemic area for CL, CL was suspected and confirmed by slit skin smear and skin biopsy. The latter demonstrated Leishmania amastigotes in the dermal histiocytic infiltrates (Figure 2). The patient is currently under treatment with systemic sodium stibogluconate (pentostam). Leishmaniasis is a major medical issue in several parts of the world. It is transmitted by sandflies. Visceral and cutaneous forms of the disease have been identified. There are more than 1.5 million cases of CL reported annually around the world (1-4). The classical form of CL can be easily diagnosed, particularly in the endemic areas. However, rare and an unusual clinical locations and presentations exist. The latter include annular, chancriform, acute paronychial, palmoplantar, zosteriform, and erysipeloid. Involvement of lower limbs is not common, but can occur (1,2). CL affecting the foot is much less commonly reported (3,4). In this location, CL can be confused with other conditions such as leprosy, vasculitis, neoplastic ulcers, and chronic ulcers due to vascular insufficiency or diabetes. Some authors have stated that routine diagnostic biopsies may be useful in case of clinically suspected wound infections, particularly in patients with deep ulcerations, diabetic foot syndrome, severe soft tissue infection, or fistula tissue. They believed that biopsies are indispensable in the microbiology workup of specific pathogens such as mycobacteria, Leishmania, actinomycetes, Nocardia ssp., or molds (5). The present case highlights the importance of proper investigation of foot ulcer and the importance of considering the diagnosis of leishmaniasis, particularly in endemic areas.