Track

Abstract

A 39-year-old female presented with a non-healing ulcer on the left upper arm characterized by a central ulceration with indurated borders. Histopathologic examination of a punch biopsy at the ulcer margin revealed epidermal ulceration overlying dense granulomatous inflammation composed of histiocytes, multinucleated giant cells, and a prominent lymphoplasmacytic infiltrate. Notably, multinucleated giant cells demonstrated elastophagocytosis, with engulfed fragmented elastic fibers, an uncommon but distinctive feature reflecting chronic tissue remodeling. Elastophagocytosis is an under-recognized but distinctive histopathologic feature in chronic cutaneous leishmaniasis that provides a valuable diagnostic clue when parasites are scarce or absent. Careful evaluation identified a small cluster of 5–6 oval intracellular amastigote-like organisms within histiocytes, alongside few degenerated forms. Special stains, including PAS-D and modified Giemsa (Diff-Quik), were negative for fungi and other pathogens. Cutaneous leishmaniasis exhibits diminished parasite burden in late-stage lesions, often complicating diagnosis. The presence of elastophagocytosis serves as an important histologic clue amidst sparse organisms. Recognizing this feature alongside subtle morphologic findings and correlating with clinical history is critical for accurate diagnosis. This case underscores the diagnostic challenge posed by late-stage cutaneous leishmaniasis and highlights elastophagocytosis as a useful morphologic marker to raise suspicion, especially in non-endemic settings or when special stains fail to detect organisms. Meticulous histopathologic assessment remains essential to guide appropriate clinical management.