Case presentation

I2 蔡哲楷

Case A previously healthy 19-year-old woman, who

had spent several months of the previous year as a student in Brazil, presented at an emergency department complaining of stuffy nose and painful ulcers on her lips and mouth, as well as on her nasal mucosa. When she returned from Brazil the previous year, she had noted multiple skin lesions on her arm, which had since disappeared. Lymphadenopathy was noted on physical examination. A biopsy specimen was taken from the edge of an ulcer.

Biopsy

A section stained with hematoxylin and eosin showed macrophages containing small, oval parasites, measuring 2 to 3 um

QUESTION(1)

Which infection does this patient have? What is the name of the hemoflagellate causing her infection? Ans: (1)Mucocutaneous Leishmania (2) Leishmania braziliensis

QUESTION(2)

Name the four main species belonging to this complex

Ans:L. (V.) braziliensis (Espundia) L. (V.) guyanensis (Painbois 痛癤 ) L. (V.) panamensis L. (V.) peruviana (Uta)

QUESTION(3)

Which vector is responsible for the transmission of this infection?

Ans:Lutzomyia sandfly

QUESTION(4)

How does the life cycle of this parasite

differ from that of other species?

QUESTION(4)

QUESTION(5) How is the diagnosis of this

infection made? Ans: (1)Hx:travel Hx,contact

Hx (2)P.E.:Cutaneous lesions Mucosal lesions

QUESTION(5)

(3)Biopsy with microscopy

(4)Culture(often scant)

QUESTION(6)

Do you think there is a connection between the patient’s previous skin lesions on her arm and the mucosal lesions she now has? What course does this infection take if untreated?

QUESTION(6) Ans: (1)Mucocutaneous leishmaniasis

can be the primary manifestation of the disease, but the primary lesions may also be limited to cutaneous manifestations, with mucosal lesions appearing only later in the course of disease when untreated cutaneous lesions progress to involve the oral and nasal surfaces. Initial symptoms related to mucosal lesions may include nasal obstruction and bleeding.

QUESTION(6) (Without treatment,

the entire nasal mucosa and palates become deformed with ulceration and erosion of the nasal septum, lips, and

palate.

QUESTION(7) Where is this hemoflagellate usually

found? Where is the risk of exposure to infection greatest?

Ans: Brazil, Peru, Ecuador, Bolivia, Venezuela, Paraguay, and Columbia

QUESTION(8) . How is this infection

treated?

Antimony sodium gluconate

 IV, IM  10 mg kg qd (max:600mg qd) for 6~10 days

  Pentavalent antimonyb IV 20 mg SbV/kg qd for 28 days

  Amphotericin B (deoxycholate)

IV 0.25~1 mg/kg qod or qd

  AlternativePentamidine isethionate

IV, IM 2–4 mg/kg qod or thrice weekly for ≥15 doses

Thank you………^_^