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31 year old man presents with a verrucal skin lesion on dorsal lower right forearm/wrist. He reports no pain or itching at site. Lesion was crusty and red around edges. No systemic complaints. Patient had extensive travel in the last 10 years to Middle East, Asia, Europe and South America. Most recently he had been doing research in South America (Peru). Patient reported no bug spray or mosquito net use while doing research. He said the lesion appeared as a papule about 4 weeks after his return to the U.S. and enlarged over about a month to the size it was at presentation, and has been present a total of 6 weeks.
What is your diagnosis?
Biopsies were performed and sent to a dermatopatholigist and additional specimens were obtained and sent to Walter Reed National Medical Center, per their instructions.
Dermatopathology, PCR and Culture all indicated:
Diagnosis:
Leishmaniasis (Leishmaniasis braziliensis)
Because the lesion was non-articular, and was singular, I recommended Bactrim DS, twice daily for 8 weeks.
The patient was a biology graduate student and had extensive “consultations with Dr. Google” and was very concerned that he may develop muco-cutaneous lesions later in life (braziliensis is a new world form), he refused to fill/use the Bactrim and returned 4 weeks later, lesion unchanged, and insisted on being treated with IV antimonials. I referred him to an Infectious Disease specialist. The ID physician consulted with the CDC and received current treatment instructions and the physician arranged 3 weeks’ worth of Pentostam treatments at an infusion center at a local hospital.
Treatment Course:
He reported fatigue with treatments, but was able to work shortened days. After 1 week of treatments the skin lesion resolved and patient was left with a scar like a “cigar burn”. He reported being lightheaded, “fuzzy” thoughts, severe headache, severe muscle weakness, cramping, and stiffness in joints to the point that he had trouble lifting his arms. Symptoms became worse as treatment progressed. Patient reported symptoms mostly resolved 1 week after end of treatment, but reports still being stiff. He reports elevated ALT/AST to the point where CDC recommended a weekend off from the treatment, but he was able to resume after this break.
He is currently studying out of the country but will follow up upon his return.
References:
- http://en.wikipedia.org/wiki/Leishmaniasis
- Transcript of Dialogues in Dermatology “Leishmaniasis” March 2011
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