Case Number : Case 4004 - 26 May 2022 Posted By: Saleem Taibjee

I was thinking of primary syphilis..., before reading clinical history...I don’t know.  I think CPC is mandatory here,  ton rule out infectious diseases like fungus, tbc, ....

Granulomatous/histiocytic inflammation, wide differential. I also wonder if malakoplakia is a possibility

Lesion with granulomatous inflammation on the cheek of a boy raises several possibilities. Idiopathic facial aseptic granuloma  is a possibility if it's a single nodule. Borderline tuberculoid leprosy with a severe type 1 reaction can lead to ulceration as can lupus vulgaris. We do not know if the boy comes from leprosy endemic area. Stains for acid fast bacilli and PCR for mycobacterial antigens may lead to the diagnosis. Granulomatous rosacea (IFAG may be a variant of it) may also be considered depending on the clinical features. Ulceration favours mycobacterial etiology.

Hi. This recent case depended upon PCR. Despite careful scrutiny of the H&E (in particular the granulomatous area directly beneath the epidermis), I could not identify organisms. However, PCR confirmed Leishmania tropica. The patient had travelled to an endemic area.

BW
Saleem