Perineurial infiltration: Not always leprosy


Post kala-azar dermal leishmaniasis, generally develops 6 months 10 years after apparent successful cure from visceral leishmaniasis. Rarely, it shows the feature of perineurial infiltration. This causes diagnostic confusion with tuberculoid leprosy, especially in countries like India, where leprosy is endemic.

Keywords: Perineurial infiltration, post kala-azar dermal leishmaniasis, Leishmania donovani bodies

How to cite this article:
DasGupta S, Mukherjee S, Das RN, Chatterjee U, Chtterjee M. Perineurial infiltration: Not always leprosy. Ann Trop Med Public Health 2014;7:195-6


How to cite this URL:
DasGupta S, Mukherjee S, Das RN, Chatterjee U, Chtterjee M. Perineurial infiltration: Not always leprosy. Ann Trop Med Public Health [serial online] 2014 [cited 2021 Jan 23];7:195-6. Available from:


Brief Communication

Leishmaniases comprises of a group of poverty-related neglected tropical diseases whose spectrum ranges from cutaneous to visceral forms and includes post kala-azar dermal leishmaniasis (PKDL). The occurrence of PKDL is confined to two geographically distinct zones, namely South Asia (India, Bangaldesh and Nepal) and East Africa (mainly Sudan) and generally occurs as a sequel of visceral leishmaniasis (VL). [1]

The characteristic skin lesions of PKDL include macules, papules, nodules, plaques and facial erythema along with mucosal involvement. [1] On histopathological examination of the Sudanese variant of PKDL, the lesions have been reported to have a diffuse infiltrate in the upper dermis comprising of lymphocytes, plasma cells and histiocytes along with formation of a macrophage granuloma with heavy parasitisation to an epithelioid cell granuloma. Other features reported in PKDL include a narrow sub-epidermal grenz zone, an atrophic epidermis and follicular plugging. [2]

Post kala-azar dermal leishmaniasis can rarely show perineurial involvement [3] and in countries endemic for leprosy and PKDL, namely South Asia and East Africa, its occurrence can be a diagnostic dilemma. This is especially so in cases of tuberculoid leprosy, where the presence of perineural infiltration is considered as a diagnostic feature. Our case is a 40-year-old male, who presented with a mixed profile of nodular, popular and macular skin lesions [Figure 1]. On clinical examination, there was a partial loss of sensation and accordingly; a preliminary diagnosis of tuberculoid variant of leprosy was initially considered. A skin biopsy was taken from a macular lesion for confirmation; however, the lesion was negative for acid fast bacilli on Wade-Fite faracco staining. Histological examination revealed an uninvolved grenz zone with a heavy and diffuse infiltration comprising plasma cells, lymphocytes and histiocytes [Figure 2]. The infiltrate showed involvement of the dermal appendages along with a prominent perineurial lymphoplasmacytic infiltration [Figure 3]. There was a notable absence of granulomas, epithelioid cells and giant cells along with an absence of lymphocytic cuffing. On further questioning the patient, he revealed a prior history of VL 2.5 years ago. However, Giemsa stained smears revealed the presence of Leishmania donovani bodies [Figure 4] and accordingly, DNA was isolated from the dermal biopsy and an internal transcribed spacer (ITS)-1 polymerase chain reaction (PCR) performed which was found to be positive and profile was comparable with published data. [4] Antibody detection by rk39 and enzyme-linked immunosorbent assay for antileishmanial antibodies was not performed as the test positivity could be attributed to the past infection of VL or the current episode of PKDL. Taken together, the clinical and histopathological features along with the ITS-1 positivity confirmed the diagnosis of PKDL, with the rare presence of perineurial infiltration.

Figure 1: Patient presenting with a mixture of papules, macules and nodular skin lesions

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Figure 2: Skin biopsy showing an uninvolved grenz zone, heavy and diffuse lymphoplasmacytic infiltration (H and E, ×100), along with perineurial infiltration (marked by arrow)

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Figure 3: A higher power view (H and E, ×400) of the dermal biopsy showing evidence of perineurial infiltration

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Figure 4: Skin biopsy showing presence of Leishmania donovani bodies, as an evidence of leishmaniasis (H and E, oil immersion view)

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The diagnosis of PKDL is generally based on clinical features, a past history of VL along with the presence of parasite in a slit smear or parasite culture positivity. Although the presence of parasite is considered as the gold standard, the method lacks sensitivity (58%), [5] as the number of parasites in skin smears, especially from macular lesions is very low. Other methods for the diagnosis of PKDL include serological tests that may be positive due to the recent occurrence of VL. To counter all these shortcomings, the PCR based ITS-1 is the most sensitive and specific [1],[4] but requires technical expertise.

The utility of S-100 staining in detection of nerve twigs within granulomas as a diagnostic aid in leprosy has been described in a few studies. [4] Although perineurial involvement is possible in both PKDL and leprosy, careful microscopic examination for involvement of the Grenz zone and presence of well defined granulomas favours a diagnosis of tuberculoid leprosy, both of which were lacking in this case. Taken together, this case cautions against labelling all cases of perineural infiltration as a feature of leprosy, emphasizing the need to also consider the diagnosis of PKDL.



Mukhopadhyay D, Dalton JE, Kaye PM, Chatterjee M. Post kala-azar dermal leishmaniasis: An unresolved mystery. Trends Parasitol 2014;30:65-74.
Ganguly S, Das NK, Barbhuiya JN, Chatterjee M. Post-kala-azar dermal leishmaniasis – An overview. Int J Dermatol 2010;49:921-31.
Rathi SK, Pandhi RK, Khanna N, Chopra P. Mucosal and peri-orificial involvement in post-kala-azar dermal leishmaniasis. Indian J Dermatol Venereol Leprol 2004;70:280-2.
Das NK, Singh SK, Ghosh S, Sarkar A, Mukhopadhyay D, Roy S, et al. Case series of misdiagnosis with rK39 strip test in Indian leishmaniasis. Am J Trop Med Hyg 2011;84:688-91.
Salotra P, Singh R. Challenges in the diagnosis of post kala-azar dermal leishmaniasis. Indian J Med Res 2006;123:295-310.

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.149508


[Figure 1], [Figure 2], [Figure 3], [Figure 4]

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