this is the first clinical report of feline viscerocutaneous leishmaniosis caused by leishmania infantum genotype e associated with an invasive squamous cell carcinoma ( scc ) in a domestic cat from portugal . initially , the cat presented a single cutaneous lesion in the right nostril . a fine - needle aspiration was performed and one year later , the cat presented a crateriform non - encapsulated and badly delineated mass in the nasal planum , with naso - oral fistulation and nasal destruction . histologically , the skin mass consisted on an ulcerative plaque - like lesion with a nasal scc . leishmania infantum mon-1 parasites were detected by histopathology , culture and pcr of the skin mass , submandibular and popliteal lymph nodes , liver and spleen . restriction enzyme analysis revealed genotype e , previously identified in humans and dogs living in the same region . this is , to the best of our knowledge , the first clinical report of feline viscerocutaneous leishmaniosis caused by l infantum genotype e. the detection and isolation of parasites from a cat that are genetically identical to the ones obtained from humans and dogs with visceral leishmaniosis highlights the need to clarify whether cats play a role in the epidemiology of this parasitic zoonosis . from a clinical point of view , this case reinforces the importance of including leishmaniosis in the differential diagnoses of feline pathology , especially in cats with cutaneous lesions . zoonotic visceral leishmaniosis caused by leishmania infantum is a serious public health and veterinary problem in the mediterranean basin . although dogs are the major host for this parasite and the main reservoir for human infection , it has been proven that cats can be experimentally infected with strains of leishmania chagasi ( syn l infantum ) . in the past few years the number of feline leishmaniosis ( fel ) case reports has increased in several countries where this zoonosis is endemic , probably owing to higher awareness of veterinarians about the occurrence of this parasitosis in cats and to the development of more sensitive methods to detect it , such as pcr . in portugal , one visceral and two cutaneous cases of fel have been reported . the present report describes the first case of disseminated viscerocutaneous fel caused by l infantum genotype e associated with an invasive squamous cell carcinoma ( scc ) in a cat from lisbon , portugal . in january 2011 , a 10-year - old unneutered domestic shorthair ( european breed ) female cat weighing 5 kg was presented for veterinary consultation . the cat lived on the street and was adopted after receiving treatment for multiple pelvic fractures . at that time , the animal presented with vaginal bleeding , abdominal bruising , pale mucous membranes , slow capillary refill time , severe pain in the lumbosacral region , absence of anal sphincter reflex and a small ulcerated lesion in the right nostril ( 2 mm ) . the cat tested negative for feline immunodeficiency and feline leukaemia viruses . in january 2012 , clinical examination revealed a general good condition with a single ulcerated cutaneous lesion ( 1 cm in diameter ) in the right nostril ( figure 1a ) . a fine - needle aspiration was performed and leishmania amastigotes were observed in the cytoplasm of macrophages , as well as extracellularly , with the absence of neoplasia - compatible cells . the lesion was cauterised with silver nitrate and systemic treatment was established with allopurinol ( 30 mg / kg po q24h until expected healing of the lesion ) , enrofloxacin ( 5 mg / kg po q24h for 8 days ) , triamcinolone acetonid ( 1 ml / kg i m single dose ) and the immunostimulant andrographis paniculata ( 5 mg / kg po q24h for 1 month ) . the lesion was re - cauterised with silver nitrate , and enrofloxacin ( 5 mg / kg po q24h for 8 days ) and meloxicam ( 0.05 mg / kg q24h for 10 days ) were added to the treatment regimen . at the end of june 2012 the cat s owners stated that the animal was eating half the usual amount of food and appeared more prostrated with the falling of a crust from the nasal lesion ( which occurred once a week ) . abnormalities detected on physical examination were gingivitis and pain on palpation of the mouth on the right side next to the nostril , which was obstructed with secretions . the cat was treated with enrofloxacin ( 5 mg / kg po q24h for 10 days ) , meloxicam ( 0.05 mg / kg po q24h for 15 days ) , famotidine ( 1 mg / kg po q24h for 15 days ) and mirtazapine ( 0.75 mg / kg po q72h ) , and the dosage of allopurinol was increased to 50 mg / kg orally every 24 h. one month later allopurinol was discontinued owing to coprostasis . in august 2012 , the owners reported that the cat had partially recovered its appetite but sometimes choked up and had a slight discharge from the right eye . the crust had fallen and the lesion seemed less wide but deeper ( figure 1b ) . in september 2012 , the animal was anorectic and the lesion had not evolved . the cat was treated with domperidone ( 0.5 mg / kg po q24h for 1 month ) , famotidine ( 1 mg / kg po q24h for 15 days ) and a supplement of complex b vitamins . in november 2012 , the cat presented with loss of appetite and a severe gingivitis , and its upper right canine tooth was shaking . the tooth was extracted and the animal was treated with clindamycin ( 10 mg / kg po q12h for 8 days ) and meloxicam ( 0.05 mg / kg po q24h for 8 days ) . one month later , the bore of the tooth root was already filled with newly formed granulation / tumoural tissue . although the nasal lesion seemed to be more superficial , the cat s face was becoming deformed . ( a ) ulcerated cutaneous lesion in the right nostril in january 2012 and ( b ) in august 2012 ; ( c ) crateriform non - encapsulated and barely delimitated mass in the nasal planum in january 2013 ; ( d ) with nasal - oral fistulation in january 2013 , the owners reported apathy , dysphagia , anorexia and weight loss . on physical examination , a crateriform non - encapsulated and barely delineated mass was present in the nasal planum , with nasal destruction and naso - oral fistulation ( figure 1c , d ) . submandibular lymphadenopathy was also present . considering the poor prognosis , the owners requested euthanasia . a peripheral blood sample was collected for dna extraction and for serology with an indirect fluorescence antibody test ( ifat ) . necropsy was performed and , skin mass , submandibular and popliteal lymph nodes , liver and spleen biopsies were processed for in vitro culture , dna extraction and histology . macerates were also used for dna extraction using a commercial kit ( pcr template preparation kit ; roche diagnostics ) and submitted to pcr using primers designed from a kinetoplast dna minicircle sequence of l infantum . tissue samples were routinely fixed ( 10% buffered formalin ) and processed for paraffin inclusion . histologically , the skin mass consisted of an ulcerative plaque - like lesion containing islands and trabeculae of squamous cell originated in the superficial epidermis and extending deep into the dermis . the epithelial structures showed progression from basal cells at the periphery to large , polygonal keratinised cells at the centre . stromal fibroplasia was present and was severely infiltrated with macrophages , followed by lymphocytes and plasma cells . the macrophages contained variable numbers of round - to - oval amastigotes ( 12 m in width and 2 m in length ) . ( a ) nasal squamous cell carcinoma ( scc ; haematoxylin and eosin ,  40 ) . ulcerative plaque - like lesion containing islands and trabeculae of squamous cell originating in the superficial epidermis and extending deep into the dermis ( * ) . stromal infiltration of macrophages containing small ( 2 m ) unicellular basophilic microorganisms , compatible with leishmania amastigotes ( arrow ) , adjacent to islands of scc . ( c ) submandibular lymph node ( haematoxylin and eosin ,  400 ) presented an infiltration of macrophages with unicellular basophilic microorganisms compatible with leishmania amastigotes ( arrow ) the submandibular and popliteal lymph nodes presented mild follicular atrophy and expansion of medullary cords filled with foamy macrophages containing amastigotes in the cytoplasm ( see figure 2c ) . the spleen presented a low number of macrophages with leishmania species in the red pulp , whereas the liver was unremarkable and no parasites were identified . ifat was positive , with a titre of 1024 , suggesting that cats with clinical fel develop a strong humoural response to the parasite . thus , the low seroprevalence obtained in previous epidemiological surveys performed in stray and domestic cats from portugal was probably associated with the lack of clinical signs in the surveyed animals . in fact , the development of clinical signs in fel has been related to an impaired immune system due to a concurrent immunosuppresive infection / disease , such as the nasal scc reported in our case . coexistence of leishmania and neoplasia has been reported in humans , dogs and cats . in human medicine , direct involvement of leishmania species in the pathogenesis of cancer , specifically in skin and mucous membranes has been described . in fact , owing to the adverse effects that they have in the activation and function of macrophages and dendritic cells , which might permit the escape of continuously produced clones of malignant cells from efficient immune destruction , recent findings have shown that leishmania species parasites might favour the induction of carcinogenesis . however , the available data on humans also suggest that leishmaniosis may manifest itself in a more severe clinical course in the setting of a co - existent malignancy . although it can be hypothesised that in the present report leishmania species infection occurred first , as no neoplastic cells were visualised in the cytology and might have facilitated the development of malignant cells , it can equally be hypothesised that the scc , which do not always exfoliate well with fine - needle aspirates , preceded the leishmania and thus predisposed to the infection . as a skin biopsy was not undertaken at the time that the fine - needle aspiration was performed , the initial diagnosis can not be definitively proven . therefore , it is difficult to determine in the present report how many of the clinical signs ( ie , skin ulceration , lymphadenopathy ) observed in the cat were likely due to leishmania species infection and how many were due to the scc ; however , the co - existence of both were responsible for the severe clinical presentation . in addition , the immunosuppressive action of the carcinoma could be the reason why treatment with allopurinol , described to be clinically effective in fel , was not efficacious in controlling leishmania infection . leishmania species dna was amplified from lymph nodes , liver , skin and spleen , and a strain ( mfel / pt/13/imt405 ) was isolated from cultured tissues and identified by isoenzymatic typing by the centre national de rfrence des leishmania , universit de montpellier , as l infantum mon-1 , the most common zymodeme in dogs and humans with leishmaniosis in the mediterranean basin . in fact , l infantum mon-1 is responsible for > 96% of the cutaneous and visceral human cases and for 99% of canine leishmaniosis cases in portugal . analysis of the enzymatic restriction of the pcr products showed that parasites belonged to genotype e , which has previously been identified among portuguese leishmania strains isolated from immunocompromised humans and from dogs . altogether , the visceral dissemination of the infection with the same species of leishmania , zymodeme and genotype observed in humans and dogs with leishmaniosis reinforces the possible role of cats in the epidemiology of this zoonosis . in the light of the increased number of clinical cases of fel reported in the past few years in cats living in endemic areas of leishmaniosis , together with the considerable prevalence of leishmania species infection observed in several epidemiological surveys , it is important to include this parasitosis systematically among the differential diagnoses of feline pathology . nevertheless , from a public health perspective it is important to clarify whether this animal species is capable of sustaining and spreading l infantum infection .
case summarythis is the first clinical report of feline viscerocutaneous leishmaniosis caused by leishmania infantum genotype e associated with an invasive squamous cell carcinoma ( scc ) in a domestic cat from portugal . 
 initially , the cat presented a single cutaneous lesion in the right nostril . 
 a fine - needle aspiration was performed and leishmania amastigotes were observed without the presence of cells compatible with neoplasia . systemic treatment with allopurinol was started . 
 one year later , the cat presented a crateriform non - encapsulated and badly delineated mass in the nasal planum , with naso - oral fistulation and nasal destruction . 
 histologically , the skin mass consisted on an ulcerative plaque - like lesion with a nasal scc . 
 leishmania infantum mon-1 parasites were detected by histopathology , culture and pcr of the skin mass , submandibular and popliteal lymph nodes , liver and spleen . 
 restriction enzyme analysis revealed genotype e , previously identified in humans and dogs living in the same region.relevance and novel informationthis is , to the best of our knowledge , the first clinical report of feline viscerocutaneous leishmaniosis caused by l infantum genotype e. the detection and isolation of parasites from a cat that are genetically identical to the ones obtained from humans and dogs with visceral leishmaniosis highlights the need to clarify whether cats play a role in the epidemiology of this parasitic zoonosis . from a clinical point of view , this case reinforces the importance of including leishmaniosis in the differential diagnoses of feline pathology , especially in cats with cutaneous lesions .