Image 13:
A young man returned from Costa Rica with 12 ulcerating lesions of 1 to 3 cm diameter. They were painless, drained a small amount of serous material, and had slowly enlarged over the previous two months. Draining lymphatics (image below) were palpably enlarged and nodular.
Diagnosis:
This was Leishmania (V.) braziliensis. The needle aspirate of an ulcer edge revealed amastigotes, a biopsy grew Leishmania, serology with Leishmania braziliensis and donovani antigen was positive (CDC Atlanta), and the PCR for L. brazilensis was positive (National Reference for Parasitology, Canada). He responded to 3 weeks of Pentostam (Na stibogluconate) by PIC line. This sporotrichoid presentation (nodular lymphangitis) has been noted before in Central American cutaneous leishmaniasis species.
