Localised cutaneous leishmaniasis in an immunosuppressed host: the role for adjuvant photodynamic therapy after incomplete amphotericin B response

Cutaneous leishmaniasis (CL) caused by the Leishmania donovani complex is uncommon in Europe and can masquerade as malignancy. We describe an immunocompromised man in his 70s with a 15-year verrucous plaque on the right hallux initially suspected as squamous cell carcinoma. Histology revealed macrophages packed with amastigotes; PCR confirmed L. donovani complex infection and serology was strongly positive. Staging excluded mucosal and visceral disease. Systemic liposomal amphotericin B achieved partial regression. Because of persistent hyperkeratosis and the acral site, adjuvant methyl-aminolevulinate photodynamic therapy (MAL-PDT) was added and was well tolerated. One month after the final session, the lesion showed near-complete re-epithelialisation with functional recovery. This case underscores the importance of early biopsy in atypical CL and suggests that MAL-PDT may be a useful adjuvant to amphotericin B in complex CL caused by the L. donovani complex.