In the store-and-forward teledermatology modality, there is a transfer of patient medical information electronically (including history and visual data) obtained in one location to a provider who is in another location (Roman & Jacob, 2014; Warshaw, Gravely, & Nelson, 2010) The construct of the TeleDermViewPoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.
TELEDERMATOLOGY READER REPORT1
History
Chief complaint
Presenting for diagnosis and therapeutic options of a lesion.
History of present illness
A 50-year-old man presents with seven, nonitchy, nonpainful ulcerating lesions on his right arm and left leg. The lesions developed 1 month after returning from a visit to southern Italy and have persisted for 5 months. Prior treatment: triamcinolone cream without improvement. His primary symptom: nonhealing lesions. Prior biopsy: none. Other significant laboratory/study findings: none. He has no personal or family history of skin cancer or melanoma.
IMAGE QUALITY ASSESSMENT
Satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT
Interpretation of Images
Lesion A: Findings
The presented nonhealing, right arm lesion is concerning for an infectious process (Figure 1).
Lesion B: Findings
The presented nonhealing, left leg lesions are concerning for an infectious process (Figure 2).
RECOMMENDATIONS
Given the history and clinical presentation, a biopsy is indicated to direct the management. The nonhealing nature of these lesions is concerning.
Type of Visit
Refer to dermatology for face-to-face evaluation, culture, and tissue biopsy.
CLINCAL PEARL
In teledermatology, the key is to utilize the history and physical examination findings to discern the diagnosis. Given the patient's recent travel to Italy, a cutaneous infectious disease is high in the differential. This case was presented to teledermatology where a biopsy revealed that the patient had contracted cutaneous leishmaniasis (CL).
Leishmaniasis is a vector-born infection caused by the flagellate parasite species Leishmania and is transmitted by the female phlebotomine sand-fly bite (Melby, 1991). Infections are categorized into four major human diseases: localized CL, diffuse CL, mucocutaneous leishmaniasis, and visceral leishmaniasis. Localized CL takes a subclinical, self-limited course primarily affecting immunocompetent hosts. It is furthermore classified into Old World (Mediterranean basin, Central Africa, Southern Europe, and Southern Asia) and New World (Central and South America, and parts of Texas) infections. Because of the patient's recent return from Italy, we believe he contracted an Old-World form of leishmaniasis, with the most common forms being L. tropica and L. major (Oumeish, 1999).
Clinically, ulcerating lesions are nonitchy and painless with variable morphology, which contributes to its frequent misdiagnosis (Dowlati, 1996). Histology shows hallmark Leishman-Donovan bodies inside the cytoplasm of histiocytes. First-line pharmacologic treatments of CL include topical and oral antifungal agents. Cryotherapy and thermotherapy have also been shown to be effective; however, oral miltefosine is the only approved treatment by the Food and Drug Administration for CL (Ruiter, Zerp, Bartelink, van Blitterswijk, & Verheij, 2003). The reader is referred to key sources for additional information on therapeutics (Malek & Ghosn, 2012). Indeed, prompt biopsy of new skin lesions in travelers returning from endemic areas is warranted to rule out CL.
REFERENCES