Cutaneous leishmaniasis is a parasitic ulcerative disease caused by a flagellate protozoan of the genus Leishmania in the Trypanosomidae family, which spreads in nature by alternating between vertebrate hosts and insect vectors and vice versa. It is a parasitosis that can cause cutaneous and visceral damage. Palpebral localization is relatively rare, as eyelid movements prevent the vector from biting the skin in this area. We report the case of a young patient with cutaneous leishmaniasis revealed by palpebral involvement.

Clinical Observation

This is a 23-year-old patient from northern Morocco who initially consulted us with a lesion involving the upper eyelid of the left eye, with inflammatory signs opposite. Diagnosed and treated as a chalazion, the patient failed to improve and was referred for surgical treatment. 

Ophthalmological examination revealed an erythematous, edematous papulo-nodular lesion with a few crusts on the outer part of the upper eyelid (Figure 1). General examination revealed no other associated skin lesions.

A parasitological examination carried out after scraping the edges of the palpebral lesion confirmed the diagnosis.

Treatment consisted of clarytromyvin 15mg/kg/d for 10 days a month for a three-month course, with good clinical evolution of the lesion and persistence of a small palpebral scar (Figure 2).

Figure 1: Erythematous and Edematous Papulo-Nodular Palpebral Lesion with A Few Crusts

Figure 2: Almost Complete Disappearance of the Lesion After Treatment

Zoonotic cutaneous leishmaniasis (CL) is characterized by great clinical polymorphism and atypical localizations, including the eyelids. Morocco remains one of the leishmaniasis-endemic countries, with three main types of leishmaniasis:

• Cutaneous Leishmaniasis: The subject of our clinical case. Often caused by Leishmania tropica, Leishmania mexicana, Leishmania major, with exclusive involvement of the skin, without extension to deep organs or mucous membranes

• Cutaneomucosal Leishmaniasis: It is distinguished from the previous type by more extensive, deeper ulceration and a more torpid course

• Visceral Leishmaniasis: The most severe form of the disease, but the rarest

Clinically speaking, there are two types of cutaneous leishmaniasis in its palpebral localization: The dry form is common in towns and cities and begins with a slightly indurated, highly pruritic papule that evolves either into a cyst containing numerous leishmanias [1], or, more often, into an ulceration from which a yellowish liquid flows, eventually forming a crust under which the ulceration extends without ever adhering to the deeper surface; the wet form is more widespread in rural areas, with a shorter incubation period of a few weeks and a course often accompanied by lymphangitic reactions. 

Only in cases of severe immunodepression does the parasite penetrate the underlying periocular tissues. Palpebral localization is rare and may be confused with other diseases such as syphilis, tuberculosis, eyelid epitheliomas or chalazion, as in our patient's case. The diagnosis may be evoked by the clinical presentation, but must be confirmed by identification of the parasite. Smear tests or MGG-stained punctures appear to be the best means of diagnosis, as they are economical, simple, rapid and safe. Curative treatment includes conventional therapies such as antimony derivatives, Glucantime® and Pentostam®, which are used IM for 15-day courses. They have toxic effects on the cardiovascular, neurological, renal and hepatic systems [2]. Modern drugs are more numerous, less harmful and have similar effects [2]. Arabinogalactan, rifampicin, allopurinol, metronidazole and amphotericin B are just a few examples [3,4]. Physical agents such as electrocoagulation, cryoapplication, surgical excision and intralesional infiltration are used for local treatment. Prevention involves personal protection. The use of insecticides, repellents and mosquito nets.

Despite its rarity, palpebral LC should be considered in the presence of any stubborn lesion, especially in endemic areas, with a view to early management to prevent potentially serious ophthalmological side-effects. The indications for treatment depend on the clinical form and extent of the lesions.

1. Morgan, G. “Case of cutaneous leishmaniasis of the lid.” British Journal of Ophthalmology, 1965, pp. 542–546.

2. Mortemousque, B. et al. “Épidémiologie de leishmaniose cutanéomuqueuse en colombie.” Lesions Ophtalmologiques BSOF, 1996, pp. 41–43.

3. Buffet, P. et al. “Traitement des leishmanioses cutanées localisées.” Annales de Dermatologie et de Vénéreologie, 1994, pp. 503–511.

4. Golenser, J. et al. “Efficacious treatment of experimental leishmaniasis with amphotericin B–Arabinogalactan water-soluble derivatives.” Antimicrobial Agents and Chemotherapy, 1999, pp. 2209–2214.