Ulcerative lesions in returning travelers

Presenter: Shana Rissmiller,DO, Sarah Ferrer,DO, Emily Matthews,DO, Jamie Groh,DO
Dermatology Program: West Palm Hospital/ Palm Beach Consortium for Graduate Medical Education
Program Director: Dr. Robin Shecter,DO
Submitted on: May 19, 2014

CHIEF COMPLAINT:  A 51-year-old Colombian male presented to the office with an approximately 3 week history of an evolving ulcerative lesion on the left forearm.

CLINICAL HISTORY:

Signs and symptoms:  He first noticed the lesion shortly after returning from a 2 month recreational stay in Colombia. He denied any known trauma or arthropod assault. The lesion reportedly began as a non-pruritic erythematous papule. Over the course of the subsequent weeks the area enlarged, ulcerated, and became crusted. He denied fever, chills, or abdominal pain.

Previous Treatment:  Topical terbinafine

Other information:  His past medical history was only significant for hypothyroidism which was being managed with synthroid.

PHYSICAL EXAM:

Physical examination demonstrated an approximately 2.5 x 1.5 cm pink, crusted plaque with central ulceration and a raised border on the dorsal left forearm. There was no fluctuance, drainage, or sporotrichoid spread appreciated.

left forearm ulcerated plaque
Left forearm 6 weeks into treatment

LABORATORY TESTS:

None

DERMATOHISTOPATHOLOGY:

A 3mm punch biopsy was performed. Histopathological evaluation demonstrated an ulcerated lesion with a mixed inflammatory infiltrate. Giemsa staining was also preformed. At higher power, amastigotes were identified within dermal macrophages.

Low power H&E
High power H&E demonstrating amastigotes

DIFFERENTIAL DIAGNOSIS:

1.   Leishmaniasis
2.   Ecthyma
3.   Fungal
4.   Atypical mycobacteria
5.   Persistent arthropod reaction


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