Image 45: This 60 year old male spent 4 months in Burkina Faso and felt insect-like bites on his back while riding on a camel.  A week later he noted red plaques on his back at the "bite" sites which continued to enlarge, were itchy and did not respond to local steroid creams. He had no underlying illness and his hematology, renal and liver function tests were normal. He was HIV negative. These pictures were taken 4 months after the onset, when first seen by us.. What is your diagnosis? .

45

Image 45. A biopsy revealed a necrotizing granulomatous inflammation with numerous amastigote-laden macrophages. A culture of both an ulcer scraping and a punch biopsy grew a Leishmania that was PCR positive for both the genus Leishmania and L. major at the Canadian National Centre for Parasitology, McGill U and also positive for L. major by isoenzymes at WRAIR, Maryland. Amastigotes were easily visualized on impression smear of the punch biopsy. Response to IV Pentostam was uneventful. We cannot explain the atypical presentation of this case. An ulcer swab grew Staphylococcus aureus but there was little response to Cloxicillin which overlapped the first week of Pentostam therapy.