A rare presentation of visceral leishmaniasis with diffuse cutaneous involvement mimicking lepromatous leprosy

A 61-year-old male, presented with generalized skin-coloured asymptomatic dermal nodules for 5 weeks. He had a history of hypertension, right sided cerebrovascular accident and diabetes mellitus (DM).

He had hepatomegaly but no lymphadenopathy, hypopigmented patches or thickened peripheral nerves.

Two differential diagnoses considered were lepromatous leprosy (LL) and diffuse cutaneous leishmaniasis (DCL).

Slit skin smear and skin biopsy didn't reveal any evidence of leprosy which excluded LL. Though amastigotes were not seen in light microscopy, culture and PCR of both skin and bone marrow were positive for Leishmania, suggesting visceral leishmaniasis (VL).

He was started on IV sodium stiboglunate 20 mg/kg/day. After one week worsening of thrombocytopenia led to intra cerebral haemorrhage to which he succumbed.

The immuno-suppression by the disease itself and the diabetes mellitus could have led to haematogenous spread to skin resulting in his current presentation. However, post kala-azar dermal leishmaniasis is also a possibility.