Mucocutaneous leishmaniasis with laryngeal involvement and hyper-IgE mimicry in a child: a case report

Mucocutaneous leishmaniasis is an uncommon manifestation of Leishmania infection, especially in children. Even rarer is its laryngeal involvement, which may mimic chronic upper airway or immunodeficiency disorders. While MCL is usually caused by New World species, involvement by Leishmania donovani in the Indian subcontinent is exceedingly rare. This case is novel due to its atypical vocal cord involvement in a pediatric patient, initially suspected to have hyper-IgE syndrome due to elevated serum IgE and widespread skin lesions. We report a case of a 9-year-old boy from western Nepal who presented with a 4-year history of progressive skin lesions and a 3-month history of hoarseness and inspiratory stridor. Examination revealed extensive nodular and papular lesions and signs of upper airway obstruction. Investigations showed marked eosinophilia and elevated serum IgE levels. Histopathological examination of a laryngeal biopsy confirmed Leishmania donovani , supported by a positive rK39 serology. Initial therapy with amphotericin B led to an acute hypersensitivity-like respiratory event, necessitating emergency intervention. The patient was subsequently treated with oral miltefosine and intramuscular paromomycin for 10 days, resulting in marked clinical improvement with resolution of respiratory symptoms and skin lesions. This case expands the clinical spectrum of MCL and highlights laryngeal leishmaniasis as a rare differential diagnosis in pediatric patients presenting with chronic upper airway symptoms. It also underscores the importance of considering endemic parasitic infections in unusual clinical presentations, especially in resource-limited settings. The hypersensitivity reaction to amphotericin B further emphasizes the need for careful monitoring and alternative treatment protocols in pediatric populations.