University of Alabama at Birmingham

2001 Case #3

Universidad Peruana Cayetano Heredia
(Links to Other 2001 Cases are at bottom of this page)
The following case was seen in the outpatient clinic of the Tropical Medicine Institute of Cayetano Heredia Hospital in Lima by the 2001 Gorgas Course participants.
Image for 02/02/01
History: One month history of 2 ulcerating skin lesions on the back of the hand at site of some subcutaneous nodules present since late October. One week after appearance of the initial 2 lesions, a 3rd lesion appeared above the elbow on the same arm. The lesions progressed to the present state despite local therapy and dicloxacillin. The lesions are non-painful, non-pruritic and have not been purulent at any time. No fever and the patient feels well.
Epidemiology: In late October this 32 yo policeman was dropped by helicopter, along with 7 other policemen, deep into the jungle on a mission he would not disclose the exact nature of. 3 days were spent walking and sleeping on the ground at night. Presently a Lima resident but has served off and on in jungle regions from 1992-99, but all time was spent in cities and towns. He received hundreds of insect bites during the jungle mission.
Physical Examination: Afebrile. Hand lesions shown in photograph. Small subcutaneous nodules present in a lymphatic distribution up the forearm with a 3rd smaller similar appearing lesion just above the elbow. No lymphadenopathy.
Labs: Normal CBC and biochemistry. Aspirate and biopsy of lesions performed.

University of Alabama at Birmingham

2001 Case #3
Diagnosis and Discussion

Universidad Peruana Cayetano Heredia
Diagnosis: Leishmaniasis due to presumed L. braziliensis infection.
Discussion: The major differential given the onset of the lesions on the hand and the lymphatic distribution would include leishmaniasis, sporotrichosis (endemic in Peru), atypical mycobacteria, and nocardiosis. In Peru leishmaniasis would be by far the most common. The painless nature of the ulcerative lesions, the characteristic heaped up borders, relatively clean bases are most indicative of leishmaniasis.

A needle aspirate of the heaped up border of the lesion revealed diagnostic intracellular amastigote forms of Leishmania on giemsa stain. PCR for speciation is pending.

Of note, 3 of the other 7 accompanying policemen also have biopsy proven leishmaniasis with from 2 to 5 lesions. The ulcers are in varying sizes (0.5 to 6 cm in diameter) despite the identical time of acquisition and are on various parts of the upper body including chest and back. Since the Lutzomyia vector (sandfly) only bites on exposed skin this suggests that they were either walking or sleeping shirtless.

In South America it is important to distinguish Leishmania species that cause only cutaneous disease from the mucocutaneous species. Both cause initial skin ulcers but with mucocutaneous species, from months to years after treatment or healing of the skin ulcers, severe destructive recurrence may occur in the mucosal surfaces of the naso and oropharynx. Although speciation is pending in the Peruvian jungle, leishmaniasis is essentially exclusively due to Leishmania braziliensis, a species causing mucocutaneous disease.

The patient was given therapy with pentavalent antimony (Glucantime) in a dose of 20 mg/kg (of antimony not of the salt) IV once per day for 20 days on an outpatient basis. The routine is to monitor renal function, liver function, CBC, and electrocardiogram before, in the middle, and at the end of therapy with an increase in frequency if the patient has any complaints or problems.