CASE Cover REPORT Story by Amy E . Hudson ; 1 Nina Copeland , APRN ; 2 Amy R . Hudson , MD 3
Abstract
Following a trip to a remote region of the Bolivian Amazon , three patients developed similar skin lesions . All three patients eventually presented to the same dermatology clinic for evaluation . We present the clinical and histopathological findings and the confirmatory test results from the Centers for Disease Control & Prevention ( CDC ).
1
Junior , Mountain Brook High School , Mountain Brook , AL .
2
Nurse Practitioner , Johnson Dermatology , Fort Smith , ARK .
3
Dermatopathologist and Laboratory Director , Johnson Dermatology , Fort Smith , ARK .
Group Trip Results in Cutaneous Parasitic Infections in Three Patients : Case Study with Clinical and Histopathological Findings
Case Reports
Approximately one month after a group trip to a remote region of the Madidi National Park in the Bolivian Amazon , a 63-year-old college professor , the organizer of the trip , developed a non-healing lesion on his left arm . His primary care physician prescribed topical antibiotic ointment ( type unknown ), and a seven-day course of Bactrim DS BID ; there was no improvement .
Communication among members of the travel group revealed that several people had similar cutaneous lesions . After researching infectious diseases endemic to the region they visited , the professor developed a high index of suspicion for leishmaniasis as a possible etiology and presented to a dermatology clinic for evaluation .
Upon examination , he had a red annular plaque with a central crust on his left arm above the elbow , approximately 3 cm in greatest dimension ( Figure 1 ). He reported occasional stinging , burning , and oozing from the lesion . Two 6 mm punch biopsies were performed . One biopsy was processed for routine histologic evaluation , and the other biopsy was sent to the Centers for Disease Control & Prevention ( CDC ) for Leishmania species identification . The patient was treated with topical gentamicin sulfate 0.1 % ointment TID until pathology results became available . Small satellite lesions subsequently developed on the same arm following his initial visit to the dermatology clinic .
Figure 1 : Red annular plaque with central crust on left upper arm of initial patient .
Routine histologic sections of one punch biopsy showed a marked lymphoplasmacytic and histiocytic infiltrate involving the dermis and subcutis , with zones of tissue degeneration . Abundant organisms morphologically compatible with Leishmania were visible in some areas ( Figure 2 ). Leishmania PCR and DNA sequencing performed by the CDC on the second punch biopsy confirmed Leishmania braziliensis as the species , and Leishmania microscopy was reported as positive by the CDC . The patient was referred to an infectious disease physician for treatment . After considering his options , the patient elected to take oral Miltefosine rather than intravenous Amphotericin B . His skin lesions resolved over time , leaving a depressed scar at the site of the initial lesion . No subsequent systemic findings developed .
Two additional members of the travel group ( ages 61 and 22 ) presented to the same dermatology clinic with similar skin lesions a week after the initial patient and were biopsied in the same manner . Histologic evaluation of the 61-year-old patient ’ s right lower leg lesion revealed similar histologic features , but with a smaller number of visible organisms . The CDC reported Leishmania braziliensis by Leishmania PCR and DNA sequencing and positive Leishmania microscopy as well . Histologic findings on the 22-yearold patient ’ s biopsy from left lower leg included extensive necrotizing granulomatous inflammation within the dermis and extending into the subcutis . However , definite parasitic organisms were not identified histologically . The CDC evaluation demonstrated Leishmania braziliensis by PCR and DNA sequencing , and the microscopy results were reported as negative for Leishmania organisms , concurring with the initial dermatopathologist ’ s impression of no visible organisms . The additional patients were also referred to an infectious disease specialist for treatment .
Discussion
Leishmaniasis is caused by any of the over 20 species of this protozoan parasite . Infection is
112 • The Journal of the Arkansas Medical Society www . ArkMed . org