Ann Saudi Med 25(3) May-June 2005 www.kfshrc.edu.sa/annals262

WHAT’S YOUR DIAGNOSIS?

From the *Department of Pathology and Oral Medicine,Baghiatallah Hospital, †Department of Pathology, Iran University Medical Sciences, Tehran, Iran

Correspondence to:Alireza Sadeghipour, MD, Assistant Professor of Pathology Department of Pathology, Iran University Medical Sciences Rasool Akram Medical Complex Sattarkhan-Nyayesh StreetP.O. Box: 14455-364Tehran, IranTel: 9-821-984005Fax: 9-821-987118asadeghipour@yahoo.com

Accepted for publication: April 2005

Ann Saudi Med. 2005;25(3):262

A 33-year-old male farmer with progressive gingival swelling and bleedingEditor: Husn FrayhaAuthors: Taghi Azizi,* Alireza Sadeghipour,† Aliasghar Roohi,* Yalda Nilipour†

A 33-year-old male farmer from eastern Iran presented with progressive gingival swelling and bleeding of several months duration. His past medical history was unremarkable. Oral

examination revealed gingival hypertrophy, especially of the upper jaw and several plaques and papules (cobblestone appearance) of the hard palate (Figures 1, 2). Systemic examination did not reveal any addi-tional cutaneous lesions, enlarged lymph nodes, or hepatosplenomegaly. e complete blood count, serum electrolytes, urea, liver function tests and chest radiography were within normal limits.

• What is the likely cause of the oral lesions?• How could the diagnosis be confirmed?

(Answer on page 268)

Figure 2. Cobblestone mucosa of the hard palate.

Figure 1. Gingival hypertrophy with bleeding.

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Ann Saudi Med 25(3) May-June 2005 www.kfshrc.edu.sa/annals270

What’s Your diagnosis?

Diagnosis: Oral leishmaniasisEditor: Husn FrayhaAuthors: Taghi Azizi,* Alireza Sadeghipour,† Aliasghar Roohi,* Yalda Nilipour†

the differential diagnosis of gingival hyperppplasia with or without hyperplasia of the palate mucosa includes inflammatory gingipp

val hyperplasia, Dilantin hyperplasia, inflammatory papillary hyperplasia, and leukemia and lymphoma. inflammatory hyperplasia of the gingiva usually reppsults from prolonged chronic inflammation of gingippval tissue, which could be associated with Vitamin C deficiency, endocrine imbalance, Crohn’s disease, or infection, including mucosal leishmaniasis. gingival hyperplasia usually begins 2 to 3 months after Dilantin therapy and is almost entirely confined to the gingival tissue surrounding the teeth. on rare occasions hyperplasia may occur in areas apart from the gingiva, such as the palate, in patients wearing a prosthetic appliance. Papillary hyperplasia occurs

Figure 1. Gingival hypertrophy with bleeding.

Figure 2. Cobblestone mucosa of the hard palate.

predominately in edentulous patients with dentures.gingival hyperplasia may be an early finding in papptients with leukemia (e.g., aML) or lymphoma, secppondary to infiltration of the gingival mucosa.

a biopsy was performed from the oral mucosal lesion. histological examination revealed pseudoppepitheliomatous hyperplasia of the squamous epippthelium with dense inflammatory infiltrates in the dermis composed of lymphocytes, plasma cells and histiocytes containing numerous amastigote forms of Leishmania (Figure 3). Bone marrow aspiration and trephine examination showed no evidence of dissemination of leishmaniasis. a diagnosis of muppcosal leishmaniasis was made and treatment was started with intramuscular meglumine antimoniate (20 mg/kg/day for 20 days). The patient showed a dramatic response and the oral lesions almost compppletely disappeared.

DiscussionLeishmaniasis is infection by protozoans of the genus Leishmania. it is one of the neglected disppeases that usually afflict the world’s poorest people. Leishmaniasis is transmitted by the bite of sandfly and presents in three forms: cutaneous, mucocutaneppous and visceral.1 Early descriptions of the parasite in cutaneous lesions were done by Cunningham, Borovsky and Wright between 1885 and 1903.2 other forms of leishmaniasis were described later. The clinical manifestation of leishmaniasis depends on the interaction between the characteristic virupplence of the species and host immune response.3 Mucosal leishmaniasis is a chronic infection of the mucosal membranes, which in most cases is prippmary but may develop during or after an attack of visceral leishmaniasis. There are at least 30 species of Leishmania, of which 12 named and several unpnamed species affect man.4 Leishmania live two quite separate lives—one in the sandfly, the other in mamppmals. in the sandfly, the organism exists as the proppmastigote (Leptomonad), and in tissue as the amastippgote (leishmanial or aflagellar form).5 These parasites are endemic to the tropics of the americas, parts of asia, Europe and tropical africa north of the equapptor.1 There are reports of mucosal leishmaniasis from different parts of the world, which almost in all cases

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Ann Saudi Med 25(3) May-June 2005 www.kfshrc.edu.sa/annals 271

DiAGnoSiS: orAl leiShMAniASiS

Figure 3. histology of the oral lesion showing macrophages containing numerous lieshman bodies (h&e stain, X400).

References1. Who expert committee. Control of leishmaniaaasis. Geneva: World health organization,1990.2. ellen C. Denigris, et al. leishmaniasis. in: pa--thology of infections? Diseases, 1st ed. Stamford: Appleton & lange, 1997:1191-1204.3. Pearson rD, Sousa AQ. Clinical Spectrum of leishmaniasis. Clin Infect Dis. 1996;22:1-13.4. lainson r, Show JJ. evolution, classifica--tion and geographic distribution in: Peters W,

Killick-Kendrick r, eds. The leishmaniases in biolaaogy and medicine. Vol.1 orlando: Academic Press, 1987:1-120.5. Chatterjee KD. leishmaniasis in: Parasitology, protozology and helminthology. 12th ed. Calcutta: Chatterjee medical publishers. 1980:53-69.6. el-hassan AM, Zijlstra ee. leishmaniasis in sudan. Mucosal leishmaniasis. Trans R Soc Trop Med Hyg. 2001 Apr;95 suppl 1:S19-26.

7. Kharfi M, Fazaa B, Chaker e, Kamoun Mr. Mucosal localization of leishmaniasis in Tu--nisia: 5 cases. Ann Dermatol Venerol. 2003 Jan;130:27-30.8. Milian MA, Bagan JV, Jimenez Y, Perez A, Scully C. oral leishmaniasis in a hiV- positive pa--tient. report of a case involving the palate. Oral Dis. 2002 Jan;8(1):59-61.

involve the upper respiratory tract and/or oral muppcosa.6p8

in iran, infection by protozoa usually leads to visceral or cutaneous disease. Primary mucocutaneppous or mucosal leishmaniasis is very rare. our case is among the few reports of this condition from iran. The clinical picture of this case appears to be more similar to the cases reported from sudan.6 More casppes need to be reported from iran to be able to present the various characteristics, which may be unique to mucosal leishmaniasis in iran.

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