Image 43: Approximately 2 months after returning from 5 weeks in Tunisia this 40 year old developed a non-tender erythematous ill-defined nodule on the dorsum of his left foot (just visible in image) and a week later a growing lesion on his left big toe. This slowly enlarged, fissured, and oozed. More then a dozen 1-2 mm pink papules appeared, scattered over the foot dorsum and within 6 weeks he noted 1-2 cm subcutaneous non-tender nodules up the lymphatic chain on the medial aspect of this below-knee leg. A physician biopsied two of these leg nodules which revealed granulomata negative on fungal and acid fast stains.They grew no mycobacteria and were LD body negative. We saw him 3 months after his illness began, did a punch biopsy and took this picture.What was the diagnosis?

43

Image 43: This was sporotrichoid cutaneous leishmaniasis, probably L. infantum. Biopsy impression smears were amastigote positive on careful search, and culture grew promastigotes positive for Leishmania spp. PCR and negative for L. major.  (PCRs performed at Nat. Ref. Centr. Parasitol.-Canada/McGill). In Tunisia there are at least 3 Leishmania species that produce cutaneous Leishmaniasis. (L. major, L. tropica and L. infantum). L. tropica and L. infantum tend to induce non-ulcerating lesions while L major tends toward an ulcerated presentation. This patient had been in the L. infantum  (coastal) and L. major region of Tunisia; hence our L. infantum diagnosis. PCRs for L. infantum are pending. Treatment was Glucantim IM and then and Pentostam IV.      

adapted from S. Boudaya, H. Turki, S. Bouassida, A Zahaf, Service de dermatologie E.P.S., Sfax, Tunisia 2002 (black dots indicate sites visited by patient)