Cutaneous leishmaniasis: an unusual cause of nasal obstruction

Nasal and sinus-related illnesses are among the most common reasons for appointments to otolaryngologists and allergists. The usual causes include septal deviation, allergic rhinitis, polyps and so on. Apart from the common cold, allergic rhinitis is probably the most common cause of nasal obstruction. Allergic rhinitis is most common during adolescence and improves significantly during middle age and wanes during old age. The anatomical causes including septal deviation and adenoids constitute other common causes of nasal obstruction. The unusual causes include middle turbinate osteoma, concha bullosa of the inferior turbinate, congenital nasal pyriform aperture stenosis, and congenital inferior turbinate hypertrophy. We describe the case of a 44-year-old man with localized cutaneous leishmaniasis, a hitherto unobserved cause of nasal obstruction, cured with intravenous sodium stibogluconate.


Introduction
Nasal and sinus-related illnesses are among the most common reasons for appointments to otolaryngologists and allergists. Some clinicians consider nasal obstruction to mean a blockage within the nasal cavity; however, nasal obstruction is most commonly defi ned as a symptom consisting of a sensation of insuffi cient airfl ow through the nose [1]. Th e usual causes include septal deviation, allergic rhinitis, polyps and so on.
We hereby describe the case of a 44-year-old man with localized cutaneous leishmaniasis (LCL) -a hitherto unobserved cause of nasal obstruction.

Case history
A 44-year-old man was sent to the Dermatology Clinic from the Otorhinolaryngology clinic with a complain of progressive blockage and deformity of the left nostril (Fig. 1a).
Th e swelling, small to start with, had progressively grown in size over the months causing deformity and diminution of the left nasal orifi ce. Th ere was no history of injury, fever, weight loss, cough, or night sweats. Th e patient was a school teacher by profession and none in his family suff ered from similar illness.
On examination, edema and deformity of the left nare were found. A large (3.5 cm × 2.5 cm) dome-shaped swelling on the left upper lip was visible. Th e surface of the swelling was smooth, slightly erythematous, nontender, and of normal temperature. Th e hair was not easily pluckable and there was no local lymphadenopathy.
Th e left nasal ala was edematous and deformed; the left nasal mucous membrane was also edematous.
Results of routine blood examination and biochemistry were within normal ranges. Skiagram of the head (lateral view and anteroposterior view), chest radiograph, and mantoux readings were within normal limits.
Th e possibilities of lupus vulgaris, sarcoidosis, and rhinoscleroma were kept in mind before proceeding further.
A full-thickness skin punch biopsy was obtained from the edge of the swelling and a part of it was sent for histopathological examination. Th e other part was used to make a touch preparation, which was air dried and stained with Romanowsky stain. On light microscopy, a mixed infl ammatory infi ltrate in the dermis (Fig. 2a) consisting of mononuclear cells, macrophages, and plasma cells was seen (Fig. 2b). On oil immersion view of the touch preparation, blue-colored intracellular inclusions identifi ed to be Leishman-Donovan bodies were seen (Fig. 2c).
On the basis of the clinical picture and microscopy fi ndings, a diagnosis of early LCL was made.
Th e patient was put on intravenous sodium stibogluconate therapy at a dose of 20 mg antimony/ kg/day. Within 2 weeks, much of the lump had disappeared (Fig. 1b); by a month, the lump had resolved without scar or pigmentation (Fig. 1c).

Discussion
Th e affl iction of cutaneous leishmaniasis has been known since olden times. Cunningham [2] observed intramacrophage organisms from lesions known as 'Delhi boil'.
Cutaneous leishmaniasis can be classifi ed as localized, diff use, recidivans, and post-kala-azar varieties, each with diff erent patterns of geographical distribution. Th e old-world parasites causing LCL are Leishmania major, Leishmania tropica, Leishmania aethiopica, and Leishmania infantum. LCL aff ects mainly unclothed areas of the body, thus aff ecting the face, neck, and the arms. Th ese areas are easily bitten by the vector, the sand fl y. Th e incubation period ranges from 1 week to 3 months; after which a red papule appears, which enlarges to a plaque or a nodule. Subsequently, this plaque or nodule breaks down to form an ulcer with a violaceous margin [3]. When left untreated, this ulcer regresses spontaneously within 6-12 months.
Infl ammation of the nasal mucosa, irrespective of the cause, may induce nasal obstruction; as a result, this symptom is very commonly complained of. Apart from the common cold, allergic rhinitis is probably the most common cause of nasal obstruction [1]. Allergic rhinitis is most common during adolescence, improves signifi cantly during middle age, and wanes during old age. Th e anatomical causes including septal deviation and adenoids constitute other common causes of nasal obstruction [1].
Th e management of nasal obstruction begins with determination of the underlying cause. Th e current patient had presented with nasal obstruction; the swelling on the lip was of little concern to the patient as it was asymptomatic. Th e patient had been sent to the dermatology clinic for evaluation of the swelling, on the presumption that the nasal pathology and the lip swelling were of diff erent pathologies. Radiological investigations ruled out bony causes. Biopsy and special stains confi rmed cutaneous leishmaniasis as the etiology for both the swelling in front of the nose as well as the edema and blockage of the nasal orifi ce. Th is was further confi rmed by the resolution of both by a common treatment.
A search of the existing literature revealed no similar instance in the past. Th is is probably the fi rst case report of nasal obstruction caused by LCL. We intend here to emphasize upon the recognition of the same as one of the causes, although unusual, of nasal obstruction.